Buena Vista Healthcare

In the surveyor’s words

From the most serious findings on record at Buena Vista Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 12, 2024

  Based on observation, interview, and record review the facility failed to implement interventions to prevent pressure ulcer/injuries for 1 of 3 sampled residents (8). Resident 8 experienced harm when they developed avoidable pressure ulcers.This failure placed other residents at risk for development of pressure ulcers, medical complications, and unmet care needs. Findings included . <Resident 8> Review of the facility's policy titled Skin Integrity updated October 2022, documented if a resident admitted with or developed a skin ulcer/pressure ulcer/wound, care would be provided to treat, heal, and prevent, if possible further development of skin ulcers/pressure ulcers/wounds. […]

• Actual harm, isolatedF689Apr 12, 2024

  Based on interview and record review the facility failed to consistently implement effective preventative measures for falls, by evaluating the effectiveness of current interventions and the need for increased supervision for 4 of 4 sampled residents (Residents 31, 33, 36, and 51), reviewed for accidents. Resident 51 experienced harm when they sustained a hip fracture requiring hospital treatment and Resident 36 experienced a pattern of frequent falls. These failures placed residents at risk for repeat falls, major injury, and diminished quality of life. Findings included . Review of the facility titled Fall Evaluation and Management dated 02/2000, showed the facility was to implement a fall management plan based on the resident's medical history and resident evaluation. […]

• Actual harm, isolatedF692Apr 12, 2024

  Based on observation, interview, and record reviewthe facility failed to provide cueing and meal assistance, monitor for significant weight loss, and risk of skin integrity for nutrition for 1 of 1 sampled residents (29). The resident experienced harm when they had an unplanned severe weight loss, nutritional decline, and breakdown of skin integrity with wound development. This failure placed other residents at risk for unplanned weight loss, medical complications, and unmet care needs. Findings icluded . <Resident 29> Review of the 03/25/2024 significant change assessment, showed Resident 29 had diagnoses which included stroke, anemia, and ataxia (impaired coordination). […]

• No harm, potential for more than minimal, patternF812Jun 13, 2026

  Based on observation and interview, the facility failed to maintain 1 of 1 ice machines (Ice Machine 1) in a sanitary manner. This failure placed the residents at risk of consuming contaminated ice and foodborne illness. Findings included.In the initial observation of the kitchen on 06/08/2026 at 10:45 AM, Ice Machine 1 was observed with thick dust debris covering the vents located on both sides of the machine. Staff D, Dietary Manager, stated the ice machine was cleaned on 06/05/2026.In a second observation of the kitchen on 06/11/2026 at 1:00 PM, Ice Machine 1 continued to be covered with thick dust debris that covered the vents located on both sides of the ice machine. […]

• No harm, potential for more than minimal, patternF583Feb 14, 2025

  Based on observation, interview, and record review, the facility failed to ensure the immediate environment of 5 of 6 sampled residents (Residents 18, 16, 24, 3, and 21) reviewed for environment, was free from visible clinical information prior to assessing if it violated the resident's privacy. Findings included . <Resident 16> An observation and interview in Resident 16's room on 02/11/2025 at 09:09 AM showed signage on the overhead light that read, 2 per FWW [ a walker], Do not bend more than 90 degrees, and Please float right heel. Additionally observed was a laminated sign on the wall and under the overhead light for posterior hip precautions. Review of a 01/27/2025 admission assessment showed the staff assessed Resident 16's cognition was intact. Resident 16 had a roommate. […]