Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Buena Vista Care Center during CMS and state inspections, most recent first.
Resident-to-resident physical abuse occurred when one resident became upset after a wheelchair bump in the dining room and struck another resident on the chin with a clenched fist during activities. The affected resident reported mouth pain and an abrasion inside the mouth, while the other resident had moderately impaired cognition and a hx of sudden angry outbursts related to psychosis; the facility also noted a prior altercation between the same two residents.
Failure to thoroughly investigate resident-to-resident abuse: the facility interviewed the two involved residents after a dining room altercation, but did not document interviews with other residents who were present and may have witnessed the event. One resident later described seeing one resident strike the other with a clenched fist, while another said she did not witness the incident. The DON/Abuse Coordinator stated staff had witnessed the event, and no additional resident witness interviews were completed.
Kitchen sanitation and hair restraint failures were observed in the dietary area. A shelving unit had peeling paint, two clean dishes had yellow food debris on them, and two dietary aides were seen working with uncovered facial hair. The DS confirmed facial hair should be covered with a hair restraint, and the facility policy required clean, sanitary equipment and proper hair restraints during food preparation.
Infection control practices were not maintained across surveillance, resident care, and supply storage. The facility’s infection logs and Infection Control Committee minutes were incomplete and inconsistent, and staff failed to perform hand hygiene during blood glucose checks and insulin administration, failed to clean an insulin pen and GT syringe properly, left expired N95 masks in a medication cart, omitted EBP signage for a resident with a wound, stored personal items in the clean linen area, and handled a resident’s bed remote without sanitizing it.
Incomplete antibiotic surveillance and missed physician follow-up: The facility failed to consistently document whether infections met McGeer's criteria and failed to show timely IP follow-up with the prescriber when residents were on antibiotics without documented true infections. For several residents, including three nonsampled residents with UTIs, the medical record did not support that the infection met criteria, yet the physician was not shown to have been notified to reevaluate antibiotic use. The IP stated follow-up was only documented in the surveillance log, not in the medical record, and the logs lacked dates/times and were incomplete.
The facility failed to document nonpharmacological interventions before giving psychotropic meds to three residents. A resident with no decision-making capacity received PRN alprazolam for agitation, another resident with no capacity received trazodone for sleep, and a third resident with severe cognitive impairment received trazodone and olanzapine without documented interventions for the antidepressant use. For the resident on olanzapine, orthostatic BP monitoring was incomplete because only lying readings were documented.
Failure to develop comprehensive care plans for two residents. One resident returned from the hospital with a new UTI dx and IV abx orders, but the care plan did not reflect the new diagnosis or related interventions. Another resident with dementia had significant unplanned wt loss and a diet order for fortified, pureed, mildly thick foods, yet the care plan did not specifically address the weight loss with measurable goals, benchmarks, or reassessment parameters.
Failure to Provide Documented Room Visits and Individualized Activities: A resident with severe cognitive impairment and significant mobility limitations had a care plan for sensory stimulation and room visits 3 times per week, but staff observations and record review showed the resident remained in bed with no other stimulation, and the chart lacked documentation of the planned activity visits. CNA staff stated the resident did not attend activities, while the Activity Assistant and Activity Director confirmed there were no activity notes to show the room visits occurred.
An LPN failed to discard the first drop of blood during fingerstick glucose checks for three residents after cleaning their fingertips with alcohol, contrary to facility policy. The same LPN also administered insulin to a resident without verifying prior injection sites, despite an order to rotate sites. The resident was able to make treatment decisions and had an order for sliding-scale insulin for DM.
Incomplete Pressure Injury Assessment Documentation: The facility failed to ensure a resident with a sacrococcyx Stage 2 pressure injury had the required wound reassessment documented. The record showed the wound was initially measured and described as a shallow open area with no drainage or infection, but the later note only stated the wound was improving and did not include required details such as length, width, depth, or exudate/necrotic tissue findings. Staff confirmed the reassessment documentation was incomplete, and the DON stated weekly assessments were completed.
A resident with dementia and on anticoagulant therapy had an unwitnessed fall and was found on the floor beside the bed with a small amount of blood and a bump to the right temporal area. The resident refused transfer to the hospital, but the neuro checks after the fall were not completed on time, with hourly assessments documented at four-hour intervals instead of every hour for four hours, and the LVN acknowledged the delay.
Pharmaceutical services were not provided accurately when oral and IV emergency med kits remained unopened past the facility’s 72-hour replacement policy, controlled pain meds were removed from the narcotic records but not documented on the MAR for two residents, and an LVN did not administer the full dose of a cranberry supplement via GT to a resident with dementia and encephalopathy.
Medication Administration Error Rate Exceeded Threshold: Surveyors found the facility’s med error rate was 23.08%, with an LVN leaving significant residue in six medication cups during administration to a resident with GT orders. The residue involved aspirin, magnesium oxide, multivitamin with minerals, prednisone, venlafaxine, and vitamin C, and the LVN confirmed the resident did not receive the correct doses. The DON stated nurses are expected to administer the complete dose.
A facility failed to ensure meals were palatable and served at an acceptable temperature for two residents. One resident reported that food was always cold and lacked taste, and beef was tough to cut and chew; another resident reported steak and pork were too tough and breakfast eggs were sometimes cold. During trayline observation, the DS stated there was no warming element on trays, and test trays showed food temperatures below the facility’s stated holding range.
Failure to provide safe food handling education for outside food. The facility permitted food brought in by family and visitors, but staff interviews and record review showed the required education was not consistently provided in a language and format families could understand. An LVN, the DSD, and the Admissions Director gave differing accounts of who was responsible, and the reviewed lesson plan and admission packet did not include safe food handling information.
Failure to maintain Washing Machine 1 in a clean and sanitary condition was identified when surveyors observed dark red, green, and white buildup on the inner door window and thick brown and white buildup on the rubber lining inside the door. The Laundry Aide stated the area could not be cleaned because it was sealed off and that there was no cleaning log, while the Maintenance Supervisor stated Laundry Aides were responsible for weekly cleaning with bleach but had no documentation of completed cleaning and acknowledged the buildup should not have been present.
A resident who was able to make treatment decisions stated she was not allowed to shave her facial hair and underarms, and staff told her the facility did not have supplies or could not assist her. Her care plan identified a need for help with personal hygiene, while staff interviews and the CNA competency checklist showed shaving assistance, including underarms, was within CNA skills and that shaving supplies were available.
Incomplete and inaccurate documentation was found for two residents. One resident with ESRD and a left-arm AV shunt had repeated BP readings charted on the restricted arm despite a care plan and MD order not to use that arm. Another resident’s POLST had Section D left blank, while social services documentation incorrectly stated the resident had an advance directive; the SSD confirmed the POLST should have been completed and the record was inaccurate.
A resident reported experiencing verbal and physical abuse from a roommate, but the facility's investigation did not include an interview with the roommate involved. Instead, only the reporting resident and another resident were interviewed, as the SSD was instructed by the Administrator to limit the interviews. This omission resulted in an incomplete investigation of the abuse allegation.
A resident with diabetic ulcers did not receive the prescribed wound care as an LVN used Gentell wound cleanser instead of the ordered normal saline. The DON confirmed that treatments should follow physician orders and any changes should be clarified.
A facility failed to implement a physician's order for bilateral floor mats for a resident at high risk for falls. Observations revealed that only one floor mat was placed, contrary to the care plan. Staff interviews confirmed the oversight, acknowledging the resident's fall risk and the need for proper fall prevention measures.
A facility failed to consistently provide non-pharmacological pain interventions before administering acetaminophen to a resident, as required by their policy. The resident, unable to make decisions, had orders for pain monitoring and non-drug interventions, but the MAR lacked documentation of these interventions on several occasions. The DON confirmed the findings and acknowledged the expectation for nurses to document non-drug interventions before medication administration.
A resident with diabetic foot ulcers did not receive an alternating pressure pad as recommended by the Wound Consultant. The facility lacked a physician's order for the pad, and the resident's medical record did not document its use. Interviews revealed that the facility did not have the pads, and the LVN did not clarify the recommendation. The Wound Consultant expected the facility to follow his recommendations or inform him if the equipment was unavailable.
A facility failed to document attempts to schedule a vascular consult for a resident with Type 2 Diabetes Mellitus, as required by their policy. Despite receiving a physician's order, RN 1 did not record her efforts to secure an appointment or her communication with a Nurse Practitioner about the delay. The DON confirmed the lack of documentation.
A survey revealed multiple food safety and sanitation deficiencies in an LTC facility, including unmonitored cool down processes for TCS foods, unsanitized food preparation surfaces, and unwashed produce. Staff failed to follow proper hygiene practices, such as changing gloves and covering facial hair, and personal items were found in food prep areas. The kitchen environment was unclean, with structural issues and improperly stored cleaning equipment.
The facility failed to address ongoing complaints from the Resident Council about cold meals, despite repeated assurances from the dietary department to monitor food temperatures and discuss tray delivery with nursing. Observations showed that open tray carts were used instead of available enclosed carts, which could have kept meals warm. Interviews revealed a lack of effective communication and follow-up on the concerns, with several staff members not conducting assigned room rounds or asking residents about food temperatures.
The facility failed to follow prescribed menus for residents on pureed and fortified diets, affecting 20 residents on pureed diets and 27 on fortified diets. Issues included not following recipes, incorrect portion sizes, and undocumented menu substitutions. Additionally, fortified diets lacked required items like Super Soup, indicating lapses in dietary guidelines adherence.
The facility failed to follow infection control practices, affecting several residents and areas. A resident's bedside commode was not emptied regularly, causing a strong urine odor. Another resident's flush syringe touched a blanket, and an RN fanned an uncapped IV port with her hand. Infection control logs were inaccurate, and the laundry area had multiple concerns. Staff did not adhere to hand hygiene protocols, and a resident's urinary catheter bag was touching the floor. These failures risked contamination and disease transmission.
The facility failed to maintain the ice machine in safe operating conditions, as it was not cleaned and sanitized per manufacturer's instructions, and lacked an air gap to prevent backflow. The MS used an unauthorized cleaner and did not follow proper cleaning procedures, while the RD was instructed not to inspect the internal components. These deficiencies posed a potential risk to the 84 residents consuming food prepared in the kitchen.
Two residents were found self-administering medications without proper authorization or assessment. One resident, cognitively intact, had Nerve Shield Pro at the bedside without a physician's order. Another resident, with moderate cognitive impairment, had Tums tablets without documented assessment for self-administration. The facility's policy requires an interdisciplinary team assessment and care plan, which were absent in both cases.
A facility failed to develop comprehensive care plans for two residents. One resident's care plan did not address the use of a bedside commode, leading to persistent urine odor issues. Another resident's care plan failed to address psychosocial needs and did not document non-pharmacological interventions for behaviors associated with risperidone use. These deficiencies risked the residents not receiving person-centered services tailored to their needs.
Two residents in a facility were not provided with activities that met their specific needs, risking their psychosocial well-being. One resident, with developmental delay and psychosis, was not engaged in activities aligned with his interests, such as exercising and reading, due to inadequate assessment by the Activities Director. Another resident, who is blind, expressed a desire for more interaction and involvement with the Braille Institute, but the facility did not facilitate this. The activities provided were limited to room visits and listening to music.
The facility failed to securely store razors, posing a risk to two residents with cognitive impairments. An opened pack of razors was found in their bedside drawers, contrary to the facility's policy that sharp objects should be stored in the supply room. Staff interviews confirmed the oversight, and the DON verified the findings.
A facility failed to maintain proper IV access care for a resident by not labeling the IV catheter site with the required date, time, and staff initials. This was observed during a survey, and an RN confirmed the oversight. The facility's policy mandates such labeling, which was not followed in this instance.
The facility failed to follow physician's orders for oxygen therapy for two residents, with one receiving incorrect oxygen flow and another having undated oxygen tubing. These deficiencies were confirmed by nursing staff and acknowledged by the DON.
The facility failed to follow pharmaceutical procedures for two residents. One resident's Percocet was removed but not documented as administered, while another resident had medications at bedside without a physician's order or assessment for self-administration. Interviews confirmed these discrepancies.
The facility failed to document non-pharmacological interventions for a resident on risperidone and did not obtain a baseline valproic acid level for another resident. Additionally, a resident with diabetes had a change in skin condition that was observed but not documented by an LVN. These deficiencies posed a risk of inadequate monitoring.
A facility failed to properly monitor a resident's orthostatic blood pressures as ordered for olanzapine use, resulting in identical readings for lying, sitting, and standing positions. Staff interviews confirmed that blood pressures were copied rather than measured separately, contrary to physician orders and facility policy.
The facility's medication error rate was 7.69%, exceeding the acceptable limit of 5%. An LVN failed to administer medications as ordered to a resident, specifically not providing metformin with meals and omitting cholecalciferol. This was confirmed through observation and interview.
The facility failed to remove expired medications from Medication Cart C and did not store internal and external medications separately. Expired wound care products were found on the cart, and suppositories were stored alongside liquid medications due to space constraints. An LVN and the Central Supply Designee confirmed these findings, which could negatively impact residents' well-being.
The facility failed to ensure the CDM was competent in managing food services and the RD did not provide adequate oversight, potentially jeopardizing the health of 84 residents. During a survey, issues such as improper food handling, unsanitized surfaces, and non-compliance with dietary requirements were found. The RD was unaware of these issues despite performing monthly audits.
The facility failed to preserve the nutritive value of pureed vegetables by preparing them two hours before meal service and holding them on a hot steam table. This was observed when a staff member boiled and blended green beans, then held them at an inappropriate temperature, potentially affecting the nutritional needs of residents on a pureed diet. The RD confirmed that recipes should be followed, highlighting a deviation from the facility's guidelines.
The facility failed to provide 20 residents on mechanically altered diets with the appropriate form of ground meat, serving 1/2 inch chopped chicken instead of the required 1/8 inch ground meat. This discrepancy was observed during a meal service, and the Registered Dietitian confirmed that the facility's dietary protocols were not followed.
The facility failed to maintain accurate medical records for several residents, including incorrect documentation of blood pressure access for a resident on hemodialysis, incomplete treatment administration records for another resident, and an incomplete POLST form for a deceased resident. Additionally, informed consent forms for medications were not properly corrected or updated, leading to potential care issues.
The facility failed to maintain a pest-free kitchen environment, as flies were observed near the lunch meal tray line. Despite a pest control policy and multiple maintenance requests for a screen door, the back kitchen door remained open due to heat, allowing flies to enter. The CDM, DM, and Administrator were aware of the issue, but no effective solution had been implemented.
A resident with a Foley catheter was observed without a dignity bag covering the urinary drainage bag, contrary to the facility's policy on dignity. The resident, who was cognitively intact, had a physician's order for the catheter due to obstructive uropathy. An RN confirmed the lack of a dignity bag, and the DON acknowledged the deficiency.
A resident in a LTC facility was found shivering and wearing a hooded jacket due to a cold room temperature, which was verified to be below the required range by both RN 1 and the Maintenance Director. The facility's policy mandates maintaining ambient temperatures between 71 to 81 degrees Fahrenheit, but the resident's room was recorded at 68.9 degrees Fahrenheit, indicating a failure to provide a comfortable environment.
The facility did not update the care plans for two residents after their Covid-19 symptoms resolved and they were no longer on antibiotics. This oversight was confirmed during a review with an RN, posing a risk of not providing individualized care.
A facility failed to provide a sack lunch to a resident during dialysis days, despite a medical order. The resident, who was cognitively intact, reported not receiving the lunch. RN 2 confirmed the order but lacked documentation that the dietary department was informed, posing a risk for medical complications.
Resident-to-Resident Physical Abuse During Activities
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident during activities in the dining room. A staff member witnessed two residents in wheelchairs bump into each other, after which one resident became upset and hit the other resident on the chin with a clenched fist. The resident who was struck reported that he was seated in his wheelchair at a table during activities, told the other resident that prizes were for residents who participated in Bingo, and was then hit on the right side of his mouth with a clenched right fist. He stated he felt pain in his mouth and had an abrasion inside his mouth on the right side between his lips. The incident was also described in the facility’s change in condition note and in interviews with the IP and the resident who was struck. The IP stated she saw the resident become upset and hit the other resident on the chin area with a right clenched fist after their wheelchairs bumped. The abused resident was cognitively intact, and the other resident had moderately impaired cognition and a care plan for sudden angry outbursts related to psychosis. The Administrator stated the facility investigated the incident and also noted a prior March 2026 altercation between the same two residents in which one resident pushed the other and the other responded by punching the resident’s arm.
Failure to Interview Available Witnesses During Resident Altercation Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse involving two residents. The facility’s policy required that all allegations of abuse be thoroughly investigated, with interviews of the residents and any witnesses, and that witness statements be obtained in writing, signed, and dated. In this case, the investigation centered on a physical altercation in the dining room during activities, where one resident reported being struck in the mouth by another resident and said staff and two other residents were present. Medical record review showed one resident was cognitively intact. During interview, that resident stated the other resident wheeled into him, struck him in the right side of the mouth with a clenched fist, caused pain, and left an abrasion inside the mouth. The IP reported a similar incident, stating the residents’ wheelchairs bumped, the second resident became upset, and then hit the first resident on the chin with a right clenched fist. The IP also identified two other residents seated at the table with the first resident. The facility’s investigative summary documented interviews with the two involved residents, including the second resident’s claim that the first resident hit him on the cheek. However, the investigation did not document interviews with the other residents who were present and may have witnessed the incident. One of those residents later stated she had witnessed the altercation and described the second resident striking the first resident, while the other resident reported not witnessing the incident. The Administrator stated she was uncertain which residents were present and that no interviews were conducted with other residents because staff had witnessed the incident.
Kitchen sanitation and hair restraint failures
Penalty
Summary
The facility failed to ensure food safety and sanitation requirements were met in the kitchen. During observation with the Dietary Supervisor, a shelving unit was seen with peeling paint, and two dishes stored with clean dishes had yellow food debris on the sides. The facility’s sanitation policy stated that utensils, counters, shelves, and equipment are to be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas that may affect use or proper cleaning. The facility also failed to ensure hair restraints were worn in the kitchen. During an observation, Dietary Aides 1 and 2 were seen working with uncovered facial hair. When interviewed, the Dietary Supervisor stated facial hair should be covered and confirmed that all facial hair should be covered with a hair restraint. The facility’s hygiene policy stated that hair nets or caps and/or beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens.
Infection Control Practices Not Maintained
Penalty
Summary
The facility failed to maintain infection prevention and control practices across multiple areas, including surveillance documentation, hand hygiene, equipment cleaning, respiratory protection storage, and isolation signage. The Infection Prevention and Control Surveillance Logs for 2025 were incomplete and inaccurate, with many resident infection entries missing information needed to show whether McGeer’s Criteria were met. The Infection Control Committee Meeting Minutes for 2025 also contained infection counts and classifications that did not match the surveillance logs. The Infection Preventionist stated the logs had technical issues and lost data, and also verified that the committee meeting data did not match the surveillance records. Several resident-specific infection control observations showed staff did not follow hand hygiene and equipment sanitation practices. During blood glucose monitoring and insulin administration, LVN 1 and LVN 3 failed to perform hand hygiene before and after resident care and after glove removal for multiple residents. LVN 1 also failed to clean the top of Resident 77’s insulin KwikPen with alcohol before attaching a sterile needle and administering insulin. In another observation, LVN 4 used a syringe for GT medication administration and placed it back into storage without cleaning it, and visible medication residue remained on the plunger. The DON verified that the syringe should be cleaned if residue remains and that nurses should perform hand hygiene and clean the KwikPen top with alcohol before use. Additional observations showed other infection control lapses in resident care areas and supply storage. Resident 35 had a physician order and care plan for Enhanced Barrier Precautions due to a wound, but no EBP signage was posted outside the room. In the laundry room, staff personal belongings were stored in the clean linen area and were touching residents’ clean clothing. Resident 18’s bed control remote was found on the floor; CNA 3 picked it up with gloves, used it, gave it back to the resident without sanitizing it, and then continued changing the resident without changing gloves. The report also noted expired N95 masks stored in Medication Cart C, and the RN stated the cart was not routinely checked.
Incomplete antibiotic surveillance and missed physician follow-up
Penalty
Summary
The facility failed to follow up with the physician regarding residents who were receiving antibiotic therapy when their infections did not meet McGeer's criteria. Review of the facility's Antibiotic Stewardship policy showed that laboratory results and the current clinical situation were to be communicated to the prescriber as soon as available to determine whether antibiotic therapy should be started, continued, modified, or discontinued. However, the Infection Prevention and Control Surveillance Logs for 2025 were incomplete and often did not show whether infections met McGeer's criteria or whether the IP followed up with the physician. The surveillance logs showed multiple months in which infections were not documented as meeting McGeer's criteria, and there were no comments showing physician follow-up for many residents. In January, four infections were documented as not meeting criteria and the physician was noted as being notified, but for other months the logs failed to show whether infections met criteria or whether the IP contacted the physician. The IP stated she called the physician when infections did not meet criteria and documented the outcome only in the comment section of the surveillance log, but she did not document the discussion anywhere else, including the residents' medical records, and she did not have dates or times for the follow-up comments. She also stated she had technical issues and lost data for all of the 2025 surveillance logs. Review of three nonsampled residents showed the same issue. Resident 65 started antibiotics for a UTI, but the medical record did not support that the infection met McGeer's criteria, and the IP stated she should have notified the physician to reevaluate antibiotic use. Resident 46 started antibiotics for a UTI, the log stated it met McGeer's criteria, but the medical record did not support that finding, and the IP verified she should have followed up with the physician. Resident 47 started antibiotics for a UTI, the log did not show whether it met McGeer's criteria, and the medical record also did not support that the infection met criteria; the IP verified she should have followed up with the physician to reevaluate antibiotic use.
Unnecessary psychotropic medication use and incomplete monitoring documentation
Penalty
Summary
The facility failed to ensure that psychotropic medications were used with documented nonpharmacological interventions for three residents reviewed for unnecessary medications. Resident 2, who had no capacity to understand and make decisions, had an order for alprazolam 0.5 mg every 12 hours as needed for agitation/fidgeting in bed causing distress via GT, but the medical record did not show documented evidence that nonpharmacological interventions were attempted before the medication was given. RN 2 confirmed there was no documented evidence of such interventions in the record. Resident 5, who also had no capacity to understand and make decisions, had an order for trazodone HCl 50 mg at bedtime for depression manifested by inability to sleep. The medical record did not show nonpharmacological interventions attempted before administration of trazodone. LVN 3 stated the resident was taking trazodone for inability to sleep and verified there was no documented evidence of interventions prior to use. RN 2 also verified the finding and stated that trazodone and risperidone should have different nonpharmacological interventions because they are different medication classes with different targeted behaviors. Resident 7, who was non-competent and had a BIMS score of 7 indicating severe cognitive impairment, had an order for trazodone 50 mg at bedtime for depression manifested by inability to sleep and an order for olanzapine 2.5 mg daily for schizoaffective disorder manifested by verbalization that people were going to steal her clothes. The record did not show a physician's order or documented evidence that nonpharmacological interventions were implemented for the routine antidepressant use. The record also showed orthostatic blood pressure monitoring ordered for olanzapine, but only lying blood pressures were documented, with no evidence that sitting and standing pressures were monitored after the resident returned from the acute care hospital.
Failure to Develop Comprehensive Care Plans for New UTI and Significant Weight Loss
Penalty
Summary
The facility failed to develop resident-centered care plans that reflected the individual care needs of two sampled residents. Facility policy required comprehensive, person-centered care plans with measurable objectives and timetables that address residents’ physical, psychosocial, and functional needs, and the weight policy required multidisciplinary care planning for significant unplanned weight loss with goals, benchmarks, timeframes, and reassessment parameters. For one resident, the medical record showed a readmission with a new diagnosis of UTI and an order for IV ceftriaxone for seven days. The record also showed increased weakness and decline in ADL function before transfer to the acute care hospital. Review of the plan of care showed no documented evidence that the facility developed and implemented a comprehensive person-centered care plan to address the new UTI diagnosis. For the second resident, the medical record showed dementia with no capacity to understand and make decisions, along with weights declining from 165 lbs. to 144 lbs. over six months, a loss of 21 lbs. or 12.7%. The resident also had an order for fortified/high protein/consistent-carbohydrate-no added salt diet with pureed texture and mildly thick consistency, and an existing care plan addressed impaired nutritional and hydration status related to dysphagia and a mechanically altered diet. However, the plan of care did not show a documented care plan problem specifically developed to address the resident’s significant weight loss. Interviews with the RD, RN, DON, Administrator, and other nursing staff confirmed the missing care plan elements.
Failure to Provide Documented Room Visits and Individualized Activities
Penalty
Summary
The facility failed to provide the individualized and ongoing activity program needed to meet the needs and interests of Resident 67. The resident had a care plan problem dated 11/14/24 for little or no activity involvement related to immobility and physical limitation, with interventions for sensory stimulation such as music therapy, hand massage, listening to Spanish music, family visits, and occasional patio visits. The care plan also stated that activity staff would continue to provide room visits three times per week or as necessary, and that the daily schedule and treatment plan would be modified as needed to accommodate activity participation. During observation, Resident 67 was seen lying in bed with the television off and no other sensory stimulation observed. The resident’s MDS quarterly assessment showed severe cognitive impairment and substantial/maximal assistance needed for mobility. Review of the medical record did not show documentation that sensory stimulation activities or room visits were provided. CNA 4 stated the resident did not attend activities and was only gotten out of bed on shower days. The Activity Assistant stated room visits were provided but could not produce documentation of the activities during those visits, and the Activity Director verified the facility had no activity notes for the room visits.
Improper Fingerstick Glucose Testing and Insulin Site Rotation
Penalty
Summary
The facility failed to ensure proper blood glucose monitoring and insulin administration for Resident 64, Resident 66, and Resident 77. The facility’s policy for obtaining a fingerstick glucose level stated that the first drop of blood should be discarded if alcohol is used to clean the fingertips because alcohol may alter the results. During observations on 12/15/25, LVN 1 cleaned each resident’s finger with an alcohol pad, obtained a blood sample with a sterile lancet, and used the first drop of blood for the test sample instead of wasting it for all three residents. Resident 64 had been admitted with a history showing the resident was able to understand and make treatment decisions, and the physician’s order included regular insulin subcutaneously per sliding scale before meals and at bedtime for diabetes mellitus, with instructions to rotate injection sites. During the observed insulin administration to Resident 64, LVN 1 asked the resident where the insulin should be injected, and the resident chose the right arm. LVN 1 did not verify the previous insulin injection sites before administering the insulin, despite the physician’s order to rotate the injection sites. The record also showed competency documentation for obtaining a fingerstick glucose level, and LVN 1 later stated awareness of the policy to discard the first drop of blood and the order to rotate insulin injection sites, but she did not follow those requirements during the observations.
Incomplete Pressure Injury Assessment Documentation
Penalty
Summary
The facility failed to ensure necessary care and services were provided to prevent the development or worsening of a Stage 2 pressure injury for Resident 69, specifically a sacrococcyx wound. The facility’s Pressure Injuries Overview policy stated that a Stage 2 pressure injury is partial-thickness skin loss with exposed dermis, and the Pressure Ulcers/Skin Breakdown clinical protocol required documentation of a full assessment including location, stage, length, width, depth, exudates or necrotic tissue, pain assessment, mobility status, current treatments, support surfaces, and active diagnoses. Resident 69 was admitted with a sacrococcyx Stage 2 pressure injury measuring 4.0 cm by 2.0 cm by 0.1 cm, described as a shallow open wound with a red wound bed, no drainage, and no signs or symptoms of infection. A progress note documented that the MD was notified about improvement in the sacrococcyx Stage 2 pressure injury and that the resident denied pain or discomfort during wound treatment, with an order to continue cleansing with normal saline, applying zinc oxide cream, and covering with a foam dressing daily for 30 days. However, the progress note did not document a complete reassessment of the pressure injury, including wound measurements and the presence or absence of exudates or necrotic tissue, as required by facility policy. During interview and record review, staff confirmed the initial assessment and the later reevaluation, and the DON stated weekly assessments were completed, but the documentation reviewed did not show the required thorough wound assessment for the sacrococcyx Stage 2 pressure injury.
Delayed Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
The facility failed to timely monitor and document the neurological assessments for one resident after an unwitnessed fall on 5/1/25. The resident was found sitting on the floor beside the bed with a small amount of blood and a small bump at the right temporal area of the head. The resident was on an anticoagulant medication and refused transfer to an acute care hospital, and the responsible party was notified of the fall incident. Review of the neuro check flowsheet showed that the first hourly neurological assessment was completed at 0730, but the next hourly assessment was not obtained until 1132, four hours later, and the following assessment was documented at 1530, another four hours later. The resident’s H&P noted the resident was unable to understand and make treatment decisions due to dementia. During interview, the LVN verified that the neurological assessments should have been completed every hour for four hours and acknowledged that the assessments were not completed in a timely manner.
Pharmaceutical Services and Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate reconciliation and administration of medications. During inspection of Medication Room A, the oral and IV emergency medication kits were found sealed with yellow locks, and the RN stated the locks indicated the kits had been previously opened and were waiting to be replaced by the pharmacy. Review of the emergency kit logs showed the oral kit had been opened on 12/10/25 and the IV kit on 11/30/25, which was beyond the facility’s 72-hour replacement policy. The DON later verified these findings. The facility also failed to document controlled medication administration in the MAR for two residents. For one resident, the Antibiotic or Controlled Drug Record showed oxycodone/APAP 7.5-325 mg was removed on 12/9/25 at 1545 hours, but the MAR did not show administration at that time. For another resident, the record showed hydrocod/APAP 10-325 mg was removed on 12/9/25 at 2050 hours, but the MAR also lacked documentation of administration. In addition, during a medication administration observation for a resident with a history of dementia and encephalopathy, an LVN crushed a cranberry supplement tablet for GT administration, but significant tablet residue remained in the medication cup after the dose was given, and the LVN verified the resident did not receive the full dose.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with surveyors identifying a 23.08% error rate based on six medication errors out of 26 total opportunities. During a medication administration observation for Resident 2, an LVN prepared and administered multiple ordered medications via GT and other routes, including amlodipine, aspirin, atenolol, cranberry, Restasis eye drops, apixaban, furosemide, losartan, magnesium oxide, meloxicam, multivitamin with minerals, prednisone, Pro-stat, Refresh tears, venlafaxine, and vitamin C. After the medications were administered, six medication cups were found to contain significant residue, and the LVN verified the residue in the cups. The medications with residue were aspirin 81 mg, magnesium oxide 400 mg, multivitamin with minerals, prednisone 5 mg, venlafaxine 75 mg, and vitamin C 500 mg. Resident 2's record showed physician orders for these medications, including administration via GT for several of them, and the LVN stated that leaving residue in the cups resulted in the resident not receiving the correct doses. The DON also stated that licensed nurses should administer the complete dose of medications and that failure to do so could result in the resident not getting the full effect of the medication.
Cold and Tough Meals Served to Residents
Penalty
Summary
The facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for two residents who received meals prepared in the kitchen. Resident 53 stated on interview that the food was always cold and lacked taste. During a concurrent trayline observation, the Dietary Supervisor stated there was no warming element on residents’ trays to keep plates warm. Two test trays placed on the final meal cart during lunch included a regular diet and a pureed texture diet, and after the last tray was served, the trays were removed for testing. The food items on the regular diet tray, including roast beef, baked potato, and seasoned beans, did not hold temperatures above 114 degrees Fahrenheit. Resident 53’s beef was also described as tough to cut with a knife and difficult to chew. Resident 81 stated that steak and pork were too tough, hard to eat, and that breakfast eggs were sometimes cold. The Dietary Supervisor stated that anything above 110 degrees for food service was acceptable and that weekly test trays were done, but there were no specific parameters on the test tray audit for acceptable temperatures. The Dietary Supervisor acknowledged the findings.
Failure to Provide Safe Food Handling Education for Outside Food
Penalty
Summary
The facility failed to follow its policy and procedure on foods brought by family and visitors by not ensuring that safe food handling practices for outside food were explained to family and visitors in a language and format they understood. The report states that the facility permitted food brought in by visitors and family and that staff were expected to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The facility policy, revised 8/2024, specifically stated that safe food handling practices are explained to family and visitors in a language and format they understand. During interviews, LVN 4 stated that families who brought food from home were informed of the resident's diet and that food could be kept in the refrigerator for two days and then discarded, and warmed by staff. LVN 4 said the DSD was responsible for giving families information on safe food handling. The DSD stated that nurses on the floor and the admissions department were responsible for providing this information, but the education lesson plan reviewed did not include safe food handling information for family and visitors. The Admissions Director stated that the admission packet included the policy and procedure on food brought in by family and visitors, but it did not include education on safe food handling. The Administrator stated there was a poster near the nursing station that educated families and visitors regarding safe food handling.
Failure to Maintain Washing Machine in Clean and Safe Condition
Penalty
Summary
The facility failed to maintain essential equipment in a clean, sanitary, and safe operating condition for Washing Machine 1. During observation, the inner door window of the washing machine was noted to have dark red, green, and white buildup, and the rubber lining on the inside of the door was observed with thick brown and white buildup. The Laundry Aide stated she was unable to clean the part of the door with the buildup because it was meant to be sealed off, and she also stated there was no cleaning log for the washing machines. The Maintenance Supervisor stated the Laundry Aides were responsible for cleaning the two washing machines and that they should be cleaned weekly with bleach, but there was no documentation showing the cleaning had been completed. He acknowledged seeing the buildup on the inner door window and stated he had brought it up to management, but he did not have documentation showing the issue was addressed. He also stated the rubber lining inside Washing Machine 1 should have been cleaned. The Administrator, DON, and Regional Nurse Resource acknowledged the findings.
Failure to Honor Resident Shaving Preferences
Penalty
Summary
The facility failed to facilitate Resident 41’s preferences and choices for shaving her facial hair and underarms. Resident 41 stated during interview that she was not allowed to shave her facial hair and underarms at the facility, and that when she needed to shave her underarms, staff told her the facility did not have the supplies and could not assist her. The facility’s shaving policy stated that staff should review the resident’s care plan to assess special needs, and Resident 41’s care plan identified a self-care deficit with the need for assistance or dependence with personal hygiene and interventions to provide assistance with care and ADLs. Resident 41’s medical record showed she was admitted and readmitted to the facility, and her H&P documented that she was able to understand and make treatment decisions. Staff interviews showed conflicting information about shaving assistance: a CNA stated residents requesting shaving of facial hair and underarms were assisted and that shaving supplies were provided, while another CNA told Resident 41 that staff were not allowed to shave residents’ underarms. The LVN and DON stated residents could be assisted with shaving underarms and that the facility provided razors, and the DSD stated CNA competency included shaving underarms, face, legs, and arms. The DSD also confirmed CNA 2 had been signed off as satisfactory for shaving, including underarms.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the medical record for Resident 9 was complete and accurately documented regarding blood pressure measurement sites. Resident 9 had end-stage renal disease and was receiving hemodialysis, with a care plan and physician order directing staff not to check blood pressure or draw blood from the left arm. The resident’s record, however, showed multiple blood pressure readings documented on the left arm over several days. During interview and record review, an LVN verified the resident had an AV shunt on the left arm and that the nurses’ documentation showed blood pressures were taken on that arm. The resident stated he never allowed nurses to take his blood pressure on the left upper arm, and an RN confirmed the blood pressure should not be taken there to prevent infection and clot risk. The facility also failed to ensure Resident 13’s POLST and social services documentation were accurate and complete. Resident 13’s POLST had Section D left blank, while the social services review stated the resident had issued an advance directive about care and treatment. The resident’s H&P showed no capacity to make decisions, and the SSD verified that Section D should have been completed and that the social services review was inaccurate. Additional documentation in the multidisciplinary care conference showed the resident’s responsible party had declined to create an advance directive.
Failure to Interview All Involved Parties in Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving one of five sampled residents. According to the facility's policy, all allegations of abuse are to be thoroughly investigated. In this case, a resident reported experiencing problems with other residents, including verbal abuse and physical altercations, and specifically mentioned issues with a particular roommate. The facility's investigation included interviews with the reporting resident and another resident, but did not include an interview with the roommate who was directly mentioned in the allegation. The Social Services Director (SSD), who was responsible for conducting resident interviews, confirmed that she did not interview the roommate because she was instructed by the Administrator to only interview another resident. The Administrator acknowledged that the omission occurred because they had previously spoken to the roommate about compatibility issues and overlooked the need to include him in the current investigation. As a result, the investigation did not fully address the concerns raised in the abuse allegation.
Failure to Administer Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide the necessary wound care treatments for a resident's left foot wounds as ordered by the physician. The resident, who had a diagnosis of Type 2 Diabetes Mellitus with other diabetic kidney complications, was observed not receiving the prescribed care. The physician's orders specified that the resident's left mid to lateral foot diabetic ulcer and left 5th metatarsal head diabetic ulcer should be cleansed with normal saline, followed by the application of Betadine, an ABD pad, and secured with a kerlix roll of gauze every day during the day shifts for 14 days. However, during a wound care observation, an LVN was seen using Gentell wound cleanser spray instead of the ordered normal saline to cleanse the resident's wounds. The LVN acknowledged the discrepancy and confirmed that the Gentell wound cleanser and normal saline were not the same. The Director of Nursing (DON) also confirmed that the licensed nurses were expected to administer treatments as ordered by the physician and that any deviation should be clarified with the physician. The DON was informed of these findings and acknowledged the issue.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement the physician's order and plan of care for a resident who was at high risk for falls and had a history of falls with injuries. Specifically, the facility did not place bilateral floor mats as ordered by the physician to prevent falls while the resident was in bed. The resident's medical records indicated a physician's order dated 9/12/24, which required the use of bilateral floor mats for fall management. However, during observations on 12/23/24, it was noted that the resident only had a floor mat on the left side of the bed, contrary to the physician's order. Interviews with facility staff, including a CNA and the DSD, confirmed the absence of the floor mat on the right side of the resident's bed. The CNA acknowledged the resident's fall risk and the potential for the resident to attempt to get out of bed unassisted. The DSD verified that the resident should have had bilateral floor mats as per the physician's order to mitigate injuries in the event of a fall. The DON was also informed and acknowledged the findings, confirming the deficiency in implementing the fall prevention plan as ordered.
Inconsistent Pain Management Practices
Penalty
Summary
The facility failed to provide consistent non-pharmacological pain interventions for a resident before administering acetaminophen, as required by their policy. The policy, revised in October 2022, stated that non-pharmacological interventions should be considered either alone or alongside medications to manage pain. However, the medical administration record (MAR) for September 2024 showed that the resident received acetaminophen on several occasions without documented evidence of non-drug interventions being attempted first. The resident, who lacked the capacity to understand and make decisions, had physician orders to monitor pain levels and use non-drug interventions coded from 0 to 10. Despite these orders, the MAR did not reflect any non-pharmacological interventions on specific dates before administering the medication. The Director of Nursing (DON) confirmed these findings during an interview and acknowledged that nurses were expected to document any non-drug interventions attempted prior to administering pain medication.
Failure to Provide Recommended Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of new pressure ulcers and promote the healing of existing pressure injuries for a resident. The resident, who had a diagnosis of Type 2 Diabetes Mellitus and was at risk for developing pressure ulcers, had diabetic foot ulcers and was recommended by the Wound Consultant to use an alternating pressure pad. However, the facility did not provide this equipment, as there was no physician's order for the alternating pressure pad, and the resident's medical record lacked documentation of its use. Interviews with the Central Supply Staff and LVN revealed that the facility did not have the alternating pressure pads, and the LVN did not clarify the recommendation with the Wound Consultant. The Central Supply Staff confirmed that no special mattress was ordered for the resident. The Wound Consultant expected the facility to carry out his recommendations or inform him if the recommended equipment was unavailable. The Director of Nursing was informed and acknowledged the findings.
Incomplete Documentation of Vascular Consult for Resident
Penalty
Summary
The facility failed to ensure the medical record for a resident was complete and accurate, specifically regarding the documentation of attempts to obtain and schedule a vascular consult. The facility's policy and procedure for charting and documentation require that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. However, the medical record for a resident with a diagnosis of Type 2 Diabetes Mellitus did not include documentation of a physician's order for a vascular consultation being carried out. Interviews with the Medical Record Director and the DON revealed that the responsibility for carrying out the physician's order for the vascular consult fell on the nurses, specifically RN 1. RN 1 acknowledged receiving the order and attempting to schedule the consult, but the earliest available appointment was two to three months away. RN 1 informed a Nurse Practitioner of the situation but failed to document these attempts and communications in the resident's medical record. The DON confirmed the absence of documentation, acknowledging the findings.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by multiple deficiencies observed during a survey. The cool down process for time and temperature control for safety (TCS) foods was not monitored, with staff failing to keep a cooling log to ensure proper temperature control. This was confirmed through interviews with kitchen staff and the Certified Dietary Manager (CDM), who acknowledged the absence of a cool down log. Additionally, food preparation surfaces were not sanitized according to the USDA Food Code, with staff using soiled cloths and failing to use the sanitizing spray correctly. The Infection Preventionist (IP) and CDM were unaware of the proper sanitizing procedures, indicating a lack of training and oversight. Further observations revealed that fresh produce, such as lettuce, was not washed before use, contrary to the facility's policy. The CDM confirmed that the lettuce was not pre-washed by the supplier, yet salads were prepared using the unwashed lettuce. Manual dishwashing procedures were also inadequate, with no sanitizing solution or test strips available for use in emergencies. Staff were not trained in the proper manual dishwashing process, and the CDM admitted to a lack of a contingency plan if the dish machine failed. Additional hygiene and safety violations included improper glove use, with staff failing to wash hands or change gloves between tasks, and uncovered facial hair in the kitchen area. Personal items, such as drinking containers, were found in the food preparation area, and staff wore inappropriate jewelry and artificial nails during food preparation. The kitchen environment was not maintained in a clean or functional state, with dirty utensils, equipment, and structural issues such as cracked walls and bulging ceilings. Cleaning equipment was stored unsanitarily, and a food preparation sink lacked backflow prevention, posing further risks to food safety.
Facility Fails to Address Resident Council's Concerns About Cold Meals
Penalty
Summary
The facility failed to effectively address the repeated concerns of cold food raised by the Resident Council over several months. Despite the dietary department's responses to monitor food temperatures and discuss tray delivery with the nursing staff, the issue persisted. The Resident Council minutes from November 2023 to October 2024 consistently documented complaints about cold meals, with the dietary department's responses remaining largely unchanged, focusing on monitoring temperatures and discussing delivery speed with nursing. Observations and interviews revealed that the facility used open tray carts for meal delivery, which did not adequately maintain food temperatures. The Certified Dietary Manager (CDM) acknowledged that enclosed tray carts, which could help keep meals warm, were available but not used due to the time it took to load them. This decision was made despite the ongoing complaints and the availability of the enclosed carts, which were intended to address the temperature issue. Interviews with various staff members, including the Administrator, Director of Nursing (DON), and other department heads, indicated a lack of effective communication and follow-up on the Resident Council's concerns. The Administrator was unaware that open carts were being used, and the DON confirmed that the tool used for room rounds did not include questions about dietary concerns. Additionally, several staff members admitted to not conducting their assigned room rounds or not asking residents about food temperatures, further contributing to the facility's failure to address the issue adequately.
Failure to Follow Prescribed Diets and Menu Documentation
Penalty
Summary
The facility failed to adhere to the prescribed menus for residents requiring pureed and fortified diets, affecting 20 residents on pureed diets and 27 residents on fortified diets. The deficiencies included not following the standardized recipe for pureed green beans, resulting in an incorrect consistency, and not using the correct portion size for pureed meat, which could potentially impact the nutritional intake of the residents. Additionally, mashed potatoes were omitted from the pureed diet menu without proper documentation or approval from the Registered Dietitian (RD). Further issues were identified with menu substitutions that were not documented or approved by the RD. For instance, applesauce was substituted for pureed pound cake without recording the change or obtaining necessary approvals. This lack of adherence to the facility's policy on menu changes and substitutions indicates a failure to ensure that residents' nutritional needs were consistently met. The facility also did not comply with the requirements for fortified diets, as evidenced by the absence of Super Soup in the meals of residents on fortified/high protein diets. The Therapeutic Spreadsheets specified that Super Soup should be included, but it was not prepared or served, which was confirmed by the staff. These failures highlight significant lapses in following dietary guidelines and ensuring the nutritional adequacy of meals provided to residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices, impacting both sampled and nonsampled residents. Resident 41's bedside commode was not regularly emptied, leading to a strong urine odor in the hallway. The commode was found with a plastic bag half-filled with urine, and a towel on the floor was stained with yellow marks. Despite the expectation for staff to empty the commode every two hours, this was not consistently done, and there was no care plan addressing the use of the bedside commode. Additionally, Resident 61's flush syringe came into contact with a blanket, and the RN fanned the uncapped IV port with her hand, both actions contrary to infection control protocols. The facility's infection control surveillance logs were inaccurate, with discrepancies noted in the documentation of infections that met McGeer's criteria. The laundry area presented multiple infection control concerns, including the storage of dirty linens in uncovered bins, lack of an eye wash station, and improper storage of clean items in the dirty laundry area. The decorative fountain was not monitored for Legionella, and the sit-to-stand device had a non-cleanable surface due to duct tape covering a ripped area. Staff failed to follow hand hygiene protocols, as observed with CNAs and LVNs not washing hands before and after medication administration or after removing gloves. Resident 33, on enhanced barrier precautions, did not receive care with the required gloves and gown. Resident 75's urinary catheter bag was observed touching the floor, and Resident 791's water pitcher had a dark yellow buildup and was unlabeled. These failures posed a risk of contamination and transmission of communicable diseases within the facility.
Ice Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain essential equipment, specifically the ice machine, in safe operating conditions. During an observation and interview, it was found that the ice machine was not cleaned and sanitized according to the manufacturer's instructions. The Maintenance Staff (MS) admitted to cleaning the ice machine once a month, but upon inspection, black residue was found on the internal components, indicating inadequate cleaning. The MS also used a non-Manitowoc product, Nu Calgon Cleaner, which was not recommended by the manufacturer, and did not follow the specified cleaning procedure. Additionally, the ice storage bin lacked an air gap to prevent backflow, as the drainage pipe was directly connected to the sewer line. The MS confirmed the absence of an air gap and incorrectly believed it was unnecessary. The Registered Dietitian (RD) also noted that she was instructed by the MS not to inspect the internal components of the ice machine, further indicating a lack of proper oversight and adherence to safety protocols. These deficiencies were observed in a facility where 84 residents consumed food prepared in the kitchen, posing a potential risk of contamination and illness. The facility's policies and procedures, as well as the USDA Food Code, require that equipment and food-contact surfaces be clean to sight and touch, which was not adhered to in this case.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure safe self-administration of medications for two residents. Resident 69, who was cognitively intact with a BIMS score of 15, was found with two bottles of Nerve Shield Pro at the bedside, one of which was empty. The resident admitted to self-administering the supplement, which was brought by a family member, without a physician's order or documented assessment for self-administration. The facility's policy requires an interdisciplinary team assessment and a care plan for residents to self-administer medications, none of which were present in Resident 69's medical record. Similarly, Resident 35, with a BIMS score of 12 indicating moderate cognitive impairment, was observed with Tums tablets on the overbed table. The resident reported taking the medication for stomach pain, but there was no physician's order or documented assessment for self-administration. The nursing staff confirmed the absence of necessary documentation and acknowledged that medications should not be left at the bedside without proper authorization and assessment. These oversights were verified by the Director of Nursing, highlighting a lapse in adherence to the facility's medication administration policies.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident 41 and Resident 67. For Resident 41, the care plan did not address the use of a bedside commode, which led to a persistent urine odor in the hallway. Observations revealed that the bedside commode was not emptied regularly, and a towel with yellow stains was used by the resident due to difficulties in self-transferring. The staff, including CNA 1, acknowledged the odor issue but did not have a clear protocol for addressing it. Medical records confirmed that Resident 41 was sometimes continent and sometimes incontinent, yet there was no care plan to address her specific toileting needs. For Resident 67, the care plan failed to address psychosocial needs and did not document non-pharmacological interventions for behaviors associated with risperidone use. Resident 67, who has developmental delay and psychosis, was observed repeatedly expressing a desire to go to the gym, which disturbed his roommate. The medical record showed that risperidone was administered for aggressive behavior, but there was no documentation of non-pharmacological interventions. Interviews with staff, including RN 1 and the DON, confirmed the lack of documentation and the absence of a care plan that included activities such as attending a day program, which was part of Resident 67's routine prior to admission. These deficiencies posed a risk of the residents not receiving person-centered services tailored to their specific needs. The lack of a comprehensive care plan for both residents highlights the facility's failure to address essential aspects of their care, potentially impacting their quality of life and well-being.
Deficiency in Resident Activity Programs
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the specific needs of two residents, which risked not supporting their psychosocial well-being. Resident 67, who has developmental delay and psychosis, expressed a desire to go to the gym and was observed to be in a confused, child-like state. The Activities Director did not assess Resident 67's activity needs adequately, as she did not contact the previous day program where Resident 67 participated in various activities such as reading, writing, and exercising. Instead, Resident 67's activities were limited to staying in his room, looking at family pictures, and family visits, which did not align with his interests and capabilities. Resident 66, who is blind, reported a lack of staff interaction and expressed interest in re-engaging with the Braille Institute, where he was previously involved. The Activities Director did not contact any agencies like the Braille Institute to provide activities suitable for Resident 66. Instead, his activities were limited to listening to music and family visits. This lack of tailored activities for both residents indicates a deficiency in the facility's ability to meet the specific needs of its residents, potentially affecting their psychosocial well-being.
Failure to Securely Store Razors Poses Risk to Residents
Penalty
Summary
The facility failed to ensure that razors were stored securely, leading to a potential accident hazard for two residents. During an observation, an opened pack of razors was found in the bedside drawers of two residents, who were identified as having cognitive impairments. One resident was noted to have no capacity to understand and make decisions, while the other was oriented only to self and exhibited confusion. This oversight was confirmed by a Certified Nursing Assistant (CNA), who acknowledged the presence of the razors and removed them from the bedside. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), revealed that the razors were supposed to be stored in the supply room and not left at the bedside. The Director of Nursing (DON) was informed of the findings and verified the deficiency. The facility's policy and procedure for safety and injury prevention indicated that sharp objects should be put away when not in use, which was not adhered to in this instance.
Failure to Label IV Catheter Site
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the IV access for a resident, identified as Resident 66, who was reviewed for IV care. The deficiency was observed when the IV catheter site for Resident 66 was found unlabeled, lacking the required date, time, and staff initials on the dressing label. This observation was made during a survey on 10/29/24, when Resident 66 was seen in bed with the unlabeled IV site. The facility's policy and procedure for Peripheral Venous Catheter Insertion, dated March 2023, mandates that IV sites should be labeled with the date, time, and initials. An interview with RN 1 confirmed the oversight, as RN 1 verified that the IV site was not labeled as per the facility's policy. Resident 66 was admitted to the facility with a diagnosis including a urinary tract infection (UTI).
Failure to Follow Oxygen Therapy Orders and Equipment Protocols
Penalty
Summary
The facility failed to adhere to physician's orders for oxygen therapy for two residents, leading to potential inadequacies in respiratory care. For Resident 83, the oxygen concentrator was set at 4 liters per minute, contrary to the physician's order of 2 liters per minute via nasal cannula continuously every shift. This discrepancy was confirmed by both LVN 6 and RN 2 during observations and interviews. Resident 83, who has the capacity to understand and make decisions, was observed with the incorrect oxygen setting on two separate occasions. For Resident 1, the facility did not ensure that the oxygen tubing was dated as required by the facility's policy. The oxygen tubing bag was dated 10/21/24, but the tubing itself was not dated, and it should have been changed on 10/28/24. Resident 1, who is moderately cognitively impaired and lacks the capacity to make decisions, was observed receiving oxygen at 2 liters per minute via nasal cannula. RN 2 confirmed the oversight regarding the undated tubing during an interview. The Director of Nursing acknowledged these findings.
Pharmaceutical Procedure Failures in LTC Facility
Penalty
Summary
The facility failed to ensure proper pharmaceutical procedures were followed for two residents. For one resident, Percocet, an opioid-based pain reliever, was removed from the supply on six occasions but was not documented as administered in the Medication Administration Record (MAR). This discrepancy was confirmed during an interview with an LVN, who acknowledged that the medication was signed out from the controlled drug record but not recorded as administered in the MAR. Another resident was observed with medications at their bedside without a physician's order, assessment, or care plan for self-administration. The resident had a BIMS score indicating moderate cognitive impairment and was found with Tums tablets on their overbed table. Interviews with RNs revealed that no medication should be left at the bedside and that the facility had not assessed the resident for self-administration. Additionally, there was no documented physician's order for the Tums, although there was an order for a different medication for upset stomach.
Deficiencies in Medication Monitoring and Documentation
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were documented for a resident receiving risperidone, and there was no clear indication for the use of this medication. The resident, who had developmental delay and psychosis, exhibited behaviors such as yelling and whining, particularly when touched by staff. Despite these behaviors, the medical records lacked documentation of any non-pharmacological interventions attempted to manage these behaviors. Additionally, there was no baseline valproic acid level obtained for the resident, who was also receiving valproic acid for epilepsy. Another resident, who was diagnosed with diabetes and blindness, experienced a change in skin condition, specifically purple discoloration on the left upper abdominal area. This change was observed by an LVN but was not documented in the medical records. The LVN was unable to provide an explanation for the lack of documentation regarding the resident's skin condition. These failures in documentation and monitoring posed a risk of inadequate monitoring for the residents involved.
Failure to Monitor Orthostatic Blood Pressure for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic drugs by not properly monitoring orthostatic blood pressures as ordered by the physician for the use of olanzapine. The facility's policy required monitoring for adverse consequences, including cardiovascular effects, but the medical records showed that the resident's blood pressure readings were identical for lying, sitting, and standing positions on multiple occasions. This indicates that the blood pressure was not measured separately for each position as required. Interviews with facility staff, including an LVN and an RN, confirmed that the blood pressure readings were copied rather than taken separately for each position. The staff acknowledged that the blood pressure should change slightly with position changes and that the physician's order to monitor orthostatic hypotension was not followed. The Director of Nursing was informed and acknowledged these findings.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the actual rate being 7.69%. This deficiency was identified through observation, interview, and medical record review. Specifically, the facility did not ensure that LVN 3 administered medications to Resident 75 as ordered. Resident 75 had physician's orders for cholecalciferol 50 mcg to be taken once daily and metformin HCl 500 mg to be taken twice daily with meals. During a medication administration observation, LVN 3 administered metformin without meals and failed to administer cholecalciferol altogether. LVN 3 confirmed in an interview that the medications were not administered as ordered.
Medication Storage Deficiencies Identified
Penalty
Summary
The facility failed to ensure proper medication storage, as evidenced by the presence of expired medications on Medication Cart C. During an inspection, several expired wound care products, including Cutimed Epiona, Manukahd Superlite honey coated absorbent dressing, Hydrogel saturated gauze, Skintegrity Hydrogel impregnated gauze, and Aquaderm hydrogel sheet wound dressing, were found. These items had expiration dates ranging from 2020 to 2024. An LVN confirmed the findings and acknowledged that expired medications should have been removed from the cart, as per the facility's policy and procedure for medication disposal. Additionally, the facility did not adhere to its policy of storing internal and external medications separately. In the medication room, suppositories and liquid medications were stored side by side on the same shelf due to a lack of space. The Central Supply Designee confirmed this storage issue and stated that orally administered medications and suppositories were supposed to be stored separately, as outlined in the facility's policy. These storage failures had the potential to negatively impact residents' well-being and increase the risk of medication errors.
Inadequate Management and Oversight in Food Services Department
Penalty
Summary
The facility failed to ensure that the Certified Dietary Manager (CDM) was competent in managing the day-to-day functions of the food services department, and the Registered Dietitian (RD) did not provide adequate oversight. This lack of competency and oversight had the potential to jeopardize the health and well-being of the 84 residents who consumed food prepared in the kitchen. The facility's documents indicated that the CDM's job description included organizing, planning, and supervising the dietary department functions, while the RD was responsible for providing management tools to enhance the operation of the dietary department. However, during the annual recertification survey, multiple issues were identified, including improper monitoring of time and temperature during the cool down process for TCS foods, unsanitized food preparation surfaces, and inappropriate use of gloves. Additional deficiencies observed during the survey included raw vegetables not being washed prior to service, lack of sanitizing solution for manual ware washing, kitchen employees drinking in food preparation areas, and improper personal hygiene practices such as wearing artificial nails and jewelry. The kitchen environment was found to be unclean, with food preparation equipment and utensils not properly maintained. Furthermore, meal preparation did not adhere to dietary requirements, with incorrect portion sizes and unapproved menu changes. The RD confirmed performing monthly kitchen audits but was unaware of the extent of the issues found during the survey. The findings were confirmed by the Administrator and other facility staff.
Failure to Preserve Nutritive Value of Pureed Vegetables
Penalty
Summary
The facility failed to ensure the nutritive value of pureed vegetables was preserved, as observed during a survey. The deficiency was identified when pureed green beans were prepared two hours before meal service and held on a hot steam table, which could potentially affect the nutritional needs of residents on a pureed diet. The facility's policy and procedure for food preparation emphasized the importance of preserving the nutritive value of vegetables by cooking them in a small amount of water and only until tender. However, during the preparation of lunch, a staff member boiled frozen green beans with water, vegetable broth, garlic, and pepper, then blended them into a liquid consistency. The mixture was thickened and placed on a steam table, where it was held at a temperature of 129 degrees Fahrenheit until the lunch tray line began, at which point the temperature had risen to 207 degrees Fahrenheit. The Registered Dietitian confirmed that all recipes should be followed, indicating a deviation from the established guidelines.
Failure to Provide Properly Prepared Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that 20 residents on mechanically altered diets received the appropriate form of ground meat, as required by their dietary needs. The facility's Diet Manual, revised in August 2023, specified that the Mechanical Soft (Ground) diet should include meat that is ground or chopped to 1/8 inch or less. However, during an observation of the lunch meal tray line, it was noted that chopped chicken approximately 1/2 inch in size was being served to residents on the Mechanical Soft ground diet. This discrepancy was confirmed by a staff member, who initially stated that the chopped chicken was intended for the Mechanical Soft ground diets. Further investigation revealed that the facility's Therapeutic Spreadsheet indicated that residents on Mechanical Soft diets should receive two ounces of ground chicken, while those on Soft Bite Sized diets should receive two ounces of bite-sized chicken. Despite this, the staff member responsible for meal preparation was unaware of the correct dietary requirements and only ground the meat after being prompted. The Registered Dietitian confirmed that the Therapeutic Spreadsheets should be adhered to for all diets, indicating a lapse in following established dietary protocols.
Incomplete and Inaccurate Medical Records in LTC Facility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, leading to potential care issues. For Resident 33, the facility did not accurately document the blood pressure access site, despite having a care plan that specified no blood pressure checks or blood draws on the left upper extremity due to hemodialysis access. The medical records showed multiple instances where blood pressure readings were taken from the left arm, contrary to the care plan. Additionally, there were discrepancies in the documentation of Resident 33's mental capacity, with two different assessments recorded without proper correction or addendum. Resident 60's Treatment Administration Record (TAR) was incomplete, with two instances where the administration of clotrimazole cream was not documented. The Licensed Vocational Nurse (LVN) responsible for the treatment acknowledged the oversight, indicating that the treatment was completed but not recorded in the TAR as required by the facility's policy. For Resident 90, the Physician Orders for Life-Sustaining Treatment (POLST) form was incomplete, failing to indicate whether the resident had an advanced directive. This was despite the availability of an Advanced Healthcare Directive Acknowledgement Form that showed the resident did not have an advanced directive. Additionally, Resident 30's informed consent documentation for Depakote and Olanzapine was inaccurate, with dosage errors and incorrect indications not properly corrected or updated, as per the facility's policies.
Failure to Maintain Pest-Free Kitchen Environment
Penalty
Summary
The facility failed to ensure the kitchen was free from flies, posing a risk for pest contamination of residents' food. The facility's pest control policy, revised in May 2008, mandates an effective pest control program. However, documentation from a pest elimination company showed treatments for ants, roaches, mice, and rats, but did not address flies. Maintenance requests dated 7/6, 8/31, and 10/11/24, indicated a need for a screen door on the dietary and delivery doors to prevent insect entry, which had not been fulfilled. During an observation on 10/31/24, the back door of the kitchen was found open without a screen, allowing flies to enter. The CDM stated the door was left open due to heat and confirmed multiple requests for a screen door. Interviews with the DM and Administrator revealed awareness of the issue, but no effective solution had been implemented. The back door had an air curtain, but it was not effective in preventing flies from entering the kitchen.
Failure to Provide Dignity Bag for Resident's Foley Catheter
Penalty
Summary
The facility failed to ensure that a dignity bag was used to cover the urinary catheter drainage bag for a resident, identified as Resident 75, who was reviewed for Foley catheter care. This oversight was observed during a survey conducted on 10/29/24, where Resident 75 was found lying in bed with the Foley catheter bag attached to the bed without a dignity bag. The facility's policy and procedure on dignity, revised in February 2021, explicitly states that staff are expected to help residents keep urinary catheter bags covered to promote dignity and respect. Resident 75, who was cognitively intact with a BIMS score of 15, had a physician's order for a Foley catheter due to obstructive uropathy. During an interview conducted on the same day as the observation, RN 1 confirmed that all residents with Foley catheters should have a covering on the urinary bag for dignity purposes and verified that Resident 75's catheter bag was uncovered. The Director of Nursing (DON) was informed of these findings on 11/1/24 and acknowledged the deficiency.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to maintain a comfortable temperature level for Resident 33, which is a violation of the resident's right to a safe, clean, comfortable, and homelike environment. According to the facility's policy and procedure, the ambient temperature in resident areas should be maintained between 71 to 81 degrees Fahrenheit. However, during an initial tour of the facility, Resident 33 was observed wearing a hooded jacket and shivering, indicating discomfort due to the cold room temperature. The resident, who is cognitively intact with a BIMS score of 15, reported that the room temperature was always cold. Further observations and interviews confirmed the deficiency. On a subsequent visit, Resident 33 continued to express discomfort due to the cold temperature, and the room temperature was verified to be below the required range at 68 degrees Fahrenheit by both RN 1 and the Maintenance Director. The Maintenance Director used a digital thermometer to confirm the room temperature was 68.9 degrees Fahrenheit, which is below the facility's policy requirements, thus failing to provide a comfortable environment for the resident.
Failure to Update Care Plans for Resolved Covid-19 Cases
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were revised to reflect their current care needs and interventions. Resident 67 and Resident 41 both had care plans that included problems related to their Covid-19 diagnoses and the use of antibiotic medication. However, these care plans were not updated after the residents' Covid-19 symptoms resolved and they were no longer on antibiotic medication. This oversight was identified during a medical record review and interview with RN 2, who confirmed that the care plans had not been revised to reflect the changes in the residents' conditions. Resident 67 was admitted to the facility and was noted to lack the capacity to understand and make decisions, as per the history and physical examination dated 9/28/24. Despite the resolution of Covid-19 symptoms and discontinuation of antibiotic medication, Resident 67's care plan still reflected the outdated information. Similarly, Resident 41's care plan continued to list Covid-19 and antibiotic use as current issues, even though these were no longer applicable. The failure to update the care plans posed a risk of not providing individualized and person-centered care to the residents.
Failure to Provide Sack Lunch for Dialysis
Penalty
Summary
The facility failed to provide a sack lunch to a resident during dialysis days, as required by the resident's medical orders. The resident, who was cognitively intact with a BIMS score of 15, reported not receiving any sack lunch during dialysis sessions. A review of the resident's medical records confirmed an order dated January 3, 2024, allowing the resident to bring a sack lunch to the dialysis center. During an interview, RN 2 confirmed the existence of this order but was unable to provide documented evidence that a diet order form was submitted to the dietary department to ensure the resident received a sack lunch on dialysis days. This oversight posed a risk for possible medical complications for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,190 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Anaheim
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coventry Court Health Center | 0.4 mi | ★★★★★ | 3 | 0 |
| Sun Mar Nursing Center | 0.9 mi | ★★★★★ | 1 | 0 |
| Harbor Villa Care Center | 1.4 mi | ★★★★★ | 24 | 0 |
| Chapman Care Center | 1.9 mi | ★★★★★ | 23 | 0 |
| La Palma Nursing Center | 2.5 mi | ★★★★★ | 33 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Buena Vista Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.