Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 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.
Failure to Document Blood Sugar Monitoring Before Insulin Administration: A resident with DM had a physician order for bedtime insulin, but the MAR showed no documentation that blood sugar checks were completed before several evening doses when the resident refused. There was also no documentation of the refusals, education attempts, or physician notification, and the DON confirmed this was not documented in the record.
Improper Medication Refrigerator/Freezer Storage: A medication storage room had a single-door refrigerator/freezer unit instead of the pharmacy-grade two-door unit described in facility policy. Surveyors observed ice buildup in the freezer, and the ADM acknowledged the unit did not have separate doors for the refrigerator and freezer sections.
A resident admitted with acute kidney failure had a dietary order for no added salt, fluid restriction, thin liquids, and a renal diet. During tray line observation, the meal ticket listed a regular diet and the tray included a salt packet, which the DM validated. The resident’s order and the renal diet guidance both called for low salt restrictions.
Food safety was not maintained when an outdated bottle of juice remained in the refrigerator and spoiled cucumbers were left for use. During kitchen observation, the DM identified the expired juice and moldy, mushy produce, and stated that the person receiving produce should inspect foods before storage or use. Facility policies required checking produce for spoilage and discarding spoiled items, and stated that use-by dates indicate when food must be consumed or discarded.
A resident admitted after a fall with a subdural hematoma and status post craniotomy had a right temporal surgical incision documented as present on admission, but LNs repeatedly recorded that wound measurements were not taken because the resident wanted to rest and then copied this same note over several days. No wound measurements or detailed incision descriptions were completed, no care plan was developed to address treatment or monitoring of the incision, no hand-off documentation supported continuity of care, and there was no evidence the physician was notified about the wound, despite facility expectations and policy for comprehensive, individualized care planning and wound assessment.
A resident with alcohol and opioid dependence did not receive a comprehensive, person-centered care plan addressing their substance use needs. The facility failed to connect the resident to support groups, did not implement or document care plan interventions, and did not obtain necessary physician orders for medication to reduce cravings. Staff were not trained on substance abuse or overdose response prior to the resident experiencing a heroin overdose, and the care plan was not updated after the incident.
A resident with moderate cognitive impairment and a history of elopement, who was equipped with a Wander Guard device, was able to leave the facility unmonitored. Staff failed to check the Wander Guard as ordered, and the resident accessed an unsupervised smoking area lacking a Wander Guard sensor. The resident was later found offsite and returned by police, with records and interviews confirming lapses in supervision and device monitoring.
The facility did not conduct daily functional testing of the Wander Guard system for seven residents as required by the manufacturer's instructions, instead performing checks weekly and documenting results accordingly. Interviews with nursing staff and the DON confirmed the deviation from the required daily testing protocol.
A resident admitted for post-joint replacement care did not receive prescribed pain medication until the day after admission, despite vocal complaints of pain and physician orders for acetaminophen and Roxicodone. The DON confirmed that the required medication was available in the emergency supply but was not administered as per facility policy.
A resident with dysphagia and a feeding tube had conflicting orders in their medical record, with an NPO status but antibiotics ordered to be given by mouth. Nursing staff administered the medications via gastric tube without clarifying the order with the physician, and the error was not identified or corrected in a timely manner.
A facility failed to maintain a resident's restroom in good repair, compromising the resident's right to a safe and homelike environment. Observations revealed peeling paint, an inoperable ceiling fan, a toilet seat partially without its outer coating, and a loose toilet lever. Staff confirmed these issues and acknowledged the absence of work orders to address them, contrary to the facility's Preventative Maintenance policy.
A resident with hemiplegia, dysphagia, and pressure injuries did not receive consistent care plan interventions for feeding assistance and pressure injury prevention. Documentation was missing for meal intake and the presence of pressure redistribution devices on several occasions, indicating potential lapses in care.
A facility failed to position a wound vacuum pump according to manufacturer guidance for a resident. The NPWT device's pump was observed on the floor next to the resident's bed, with cables and a tube in contact with the observer's feet. Manufacturer guidance specified that the system should be positioned to avoid trip hazards. The DON acknowledged the risk of tripping or disconnection.
The facility failed to ensure dietary staff wore hair restraints during meal service, as required by policy. Observations showed two staff members without facial hair restraints while preparing meals. Interviews revealed confusion about the policy's requirements, with the Dietary Manager admitting a lack of clarity and the Administrator confirming that restraints should be worn.
A resident with Parkinson's disease and type 2 diabetes was not assessed for self-administration of medication, as required by facility policy. Despite having a BIMS score indicating intact cognition, the resident was found with a bottle of multivitamins on their bedside table, which they were taking without an assessment or approval. Facility staff confirmed the lack of assessment and stated the resident was not permitted to have the multivitamin in their room.
A facility failed to accurately code a resident's MDS, omitting hospice care despite documentation indicating its initiation. The MDS Coordinator acknowledged the oversight, and the DON and Administrator stressed the importance of MDS accuracy for care planning and reimbursement.
A facility failed to resubmit a Level I PASARR screening for a resident with depression and anxiety disorder who stayed beyond 30 days, as required by policy. Staff interviews revealed a lack of awareness and oversight regarding the need for a new screening, resulting in non-compliance with state requirements.
A resident with Parkinson's disease and type 2 diabetes was found to have a bottle of multivitamins on their bedside table, contrary to facility policy requiring secure storage. The resident, with intact cognition, stated they took the multivitamin because it was all-natural. An LVN confirmed the improper storage, and the administrator noted that medications should be secured in the bedside drawer.
A resident with intact cognition and a history of cerebral infarction experienced an unwitnessed fall while self-transferring, resulting in a skin tear. The facility failed to notify the resident's designated responsible party, despite policy requirements and the resident's Power of Attorney granting the RP authority to receive such notifications.
The facility failed to assist a resident in making an outside appointment for a cataract evaluation as per the prescriber's order. The Administrator confirmed that there was no documentation showing that staff had attempted to make the appointment before the resident was discharged. The job description for the Social Services Assistant included coordinating such appointments, and the facility's policy emphasized the resident's right to access outside services.
The facility failed to maintain a system for accounting and managing a resident's personal funds. A resident with intact cognitive abilities left $300 with the Social Services Assistant (SSA) without a signed agreement or accounting statement. The SSA kept the money in a locked safety deposit without any accounting system, and the Director of Social Services (DSS) and Administrator confirmed the absence of such a system.
Failure to Document Blood Sugar Monitoring Before Insulin Administration
Penalty
Summary
Facility staff failed to follow physician orders for Resident 11, who was admitted with diagnoses including type 2 diabetes mellitus. The physician order dated 10/6/25 directed administration of Insulin Glargine solostar pen-injection 100 unit/ml, 22 units at bedtime for DM. Review of Resident 11's MAR showed no documentation that blood sugar was taken before the 9 p.m. insulin dose on 4/1/26, 4/3/26, 4/4/26, 4/5/26, and 4/8/26 prior to resident medication refusals. There was also no documentation related to the omission or that the physician was notified that Resident 11 refused blood sugar checks on those dates. The resident's care plan identified DM with potential for hypo/hyperglycemia and included interventions to identify areas of non-compliance, modify problem areas to make them more manageable, provide documentation teaching to the resident/family, and address identified roadblocks to compliance. During interview and record review, the DON confirmed it was the facility's standard practice to obtain a blood sugar reading before insulin administration and stated that when a resident refuses blood sugar checks or insulin, staff are expected to educate the resident, attempt compliance, notify the physician, and document all interventions; the DON acknowledged there was no documentation in the record to reflect blood sugar monitoring, education, attempts to obtain compliance, or physician notification.
Improper Medication Refrigerator/Freezer Storage
Penalty
Summary
The facility failed to follow its established policies for storing pharmaceutical products when a medication storage room in Station A was equipped with a single-door refrigerator/freezer unit instead of a pharmacy-grade two-door unit with a separate freezer compartment and door. During observation, the refrigerator used for medication storage had one door for both the refrigerator and freezer sections, and ice buildup was observed in the freezer. During interview, the administrator stated that the facility did not store medication in the freezer and acknowledged that the facility’s policy was to provide a pharmacy-grade refrigerator specifically for medications to preserve efficacy, with separate doors for the freezer and refrigerator. Review of the facility’s policy and procedure titled Monitoring for Monitoring of Temperature in Refrigerator/ Freezer Containing Pharmaceutical Products, dated 2018, stated that refrigerators and freezers used to store pharmaceutical products ideally shall be pharmacy grade and be a two-door unit with a separate freezer compartment and door when combined.
Dietary Order Not Followed for Resident on Renal Diet
Penalty
Summary
The facility failed to meet the dietary prescription for one resident, who was admitted with diagnoses including acute kidney failure, unspecified. During a concurrent observation and interview at the tray line, the meal ticket for the resident indicated Regular, Fluid Restriction 1500 ml Thin Liquids, and Renal Diet, and the tray was observed with a salt packet; the Dietary Manager validated this observation and stated they would double check the dietary prescription. During a later interview and record review, the resident’s dietary order was reviewed and showed No added Salt. A review of the facility’s Renal Diet 40-60-80 Gram Protein Low Potassium, Low Salt Menu stated that the diet should include restrictions such as potassium, sodium, and fluid, with low potassium and low salt recommended.
Food Storage and Dating Deficiency
Penalty
Summary
Food safety was not maintained when an outdated bottle of juice was left in the refrigerator and spoiled produce was left for use instead of being discarded. During a concurrent observation and interview in the kitchen, a bottle of juice was found in the refrigerator with a best by date of 4/1/26. In a separate concurrent observation and interview, cucumbers were noted to have mold and to be mushy. The Dietary Manager stated that the person responsible for receiving produce should inspect foods before storage or use. Facility policies titled Storing Produce and Labelling and Dating of Foods stated that fruit and vegetables should be checked for rotten or spoiled items, spoiled items should be thrown away upon delivery, and food use-by dates indicate when food must be consumed or discarded.
Failure to Assess and Care Plan Surgical Incision on Admission
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure licensed nurses completed wound assessments and developed a care plan for a resident’s surgical incision upon admission. The resident was admitted with diagnoses including post-fall, subdural hematoma, and status post craniotomy, and the admission History and Physical documented a right temporal surgical incision present on admission. An initial body assessment on the admission date noted a new surgical wound on the right temporal area, identified as a surgical wound present on admission, but stated that measurements were not documented because the resident wanted the assessment done another day and wanted to rest. From the admission date through several subsequent days, progress notes repeatedly documented the same entry about the new surgical wound, its location, and that measurements were not taken for the same stated reason. There was no evidence in the medical record that wound measurements or a detailed description of the incision were ever completed during this period. The record also lacked a care plan addressing the surgical incision, including treatment or monitoring interventions, and there were no hand-off reports or documentation to support continuity of care among staff regarding the wound. Additionally, there was no documentation that the physician was notified about the surgical incision. In interviews, an RN described the facility’s usual process for residents with wounds, including admission assessment, notification of the treatment nurse, completion of a full assessment within 24 hours, and notification of the physician and family, and stated that nothing had changed in how wound assessments were to be done. The DON acknowledged that the resident’s medical record was missing the surgical wound assessment and confirmed there was no care plan developed for the incision, despite the facility’s care plan policy requiring individualized, comprehensive care plans for identified resident problems.
Failure to Implement Comprehensive Care Plan for Resident with Substance Use Disorders
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with known alcohol dependence, alcohol abuse, and opioid dependence. Upon admission, the resident's diagnoses and history indicated a high risk for substance use and withdrawal, with recommendations for supportive group referrals and possible medication interventions. Despite these identified needs, the facility did not ensure the resident was connected to community support groups, did not develop or sign a behavior contract, and did not provide or assist in obtaining substance use treatment services such as behavioral health support, medication-assisted treatment, or access to support meetings. Documentation revealed that although the care plan included interventions such as monitoring for cravings, room searches for paraphernalia, and working with the resident to identify coping mechanisms, there was no evidence these interventions were actually implemented. The facility also failed to obtain or document physician orders for a monthly injection to reduce substance abuse cravings, despite repeated mentions by the resident's responsible person and care team. Additionally, there was no documentation that the facility staff were trained on recognizing or responding to signs and symptoms of substance abuse, withdrawal, or overdose prior to a critical incident. The lack of implementation and follow-through on the care plan resulted in the resident experiencing a heroin overdose, requiring emergency intervention with Narcan administered by paramedics. The facility did not have an order for the opioid reversal agent, nor did staff administer it as outlined in the care plan. After the overdose, the care plan was not reassessed or updated, and there was no evidence of further action to address the resident's ongoing needs related to substance abuse and dependence.
Failure to Prevent Elopement Due to Inadequate Supervision and Wander Guard Monitoring
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed as an elopement risk and was equipped with a Wander Guard device. The resident, who had diagnoses including schizophrenia and anxiety disorder, demonstrated moderate cognitive impairment and a history of wandering and elopement. The care plan and physician's orders required the Wander Guard to be checked every shift, but documentation showed the last check occurred several days prior to the incident, and staff interviews confirmed that checks were only performed weekly, contrary to the orders and manufacturer’s instructions. On the day of the incident, the resident was discovered missing during a routine check for breakfast, prompting a facility-wide search and notification of law enforcement. The resident was later found offsite and returned by police. Review of facility records indicated that no alarms were triggered by the Wander Guard system at the monitored exits during the time the resident left. Observations and staff interviews revealed that the resident frequently accessed the designated smoking area, which was surrounded by a fence and padlocked gate but lacked a Wander Guard sensor. The resident was observed smoking alone in this area without staff supervision, despite being identified as an elopement risk. Further review of facility policy and manufacturer instructions indicated that the Wander Guard system should be tested daily, with results documented in the medical record. However, the facility’s practice was to test the devices weekly, and the policy did not specify the required frequency. The lack of adherence to the care plan, physician’s orders, and manufacturer’s guidance, combined with insufficient supervision in the smoking area, contributed to the resident’s ability to elope from the facility without detection.
Failure to Perform Daily Testing of Wander Guard System
Penalty
Summary
The facility failed to perform daily functional testing of the Wander Guard system, an alert device worn by residents to prevent unsafe wandering, as required by the manufacturer's instructions. Instead, nursing staff checked the devices weekly, with results documented in the medical record, rather than daily as specified. Interviews with nursing staff and the DON confirmed that seven residents were using the Wander Guard devices and that the facility's policy did not specify a daily testing frequency. Review of the manufacturer's instructions indicated that daily testing and documentation were required, but this was not being followed.
Failure to Provide Timely Pain Management After Admission
Penalty
Summary
A deficiency occurred when a resident admitted for aftercare following joint replacement surgery did not receive appropriate pain management upon admission. The resident, who was cognitively intact and able to communicate, reported that her last dose of pain medication was administered at the hospital prior to admission, and she did not receive any pain medication from the facility until the following day. Nursing documentation confirmed that the resident complained of pain in her left knee, rated as a level 3, but no pain medication was administered on the day of admission, despite physician orders for both acetaminophen and Roxicodone for varying levels of pain. The Medication Administration Record showed no administration of either acetaminophen or Roxicodone on the day of admission, and the first recorded dose was given the next morning, with no documented monitoring of its effectiveness. The DON confirmed that the ordered controlled pain medication was available in the facility's emergency medication supply but was not administered as required. Facility policies reviewed indicated that pain management should be provided according to professional standards and that nurses should obtain needed medications from emergency supplies if unavailable, but these procedures were not followed in this instance.
Failure to Verify Physician Orders for NPO Resident
Penalty
Summary
Staff failed to verify the accuracy of a physician's order for a resident who had a diagnosis of dysphagia following a cerebral infarction and was admitted with a feeding tube. The resident's medical record included a physician's order for NPO (nothing by mouth), yet the Medication Administration Record (MAR) contained orders for oral administration of antibiotics. Licensed nurses documented administration of these medications by mouth over several days. During interviews, the Assistant Director of Nursing confirmed the resident was NPO, and a licensed nurse stated she administered the medications via gastric tube rather than by mouth, but did not clarify the order with the physician. The Director of Nursing acknowledged that the antibiotic orders were written in error and not verified in a timely manner. This resulted in a failure to ensure the accuracy of physician orders and proper maintenance of the resident's medical record.
Restroom Maintenance Deficiency
Penalty
Summary
The facility failed to maintain a restroom in good repair for one of the sampled residents, which compromised the resident's right to a safe, clean, comfortable, and homelike environment. During an observation and interview with the Housekeeping Supervisor and Maintenance Assistant, it was noted that the restroom had peeling paint, an inoperable ceiling fan, a toilet seat partially without its outer coating, and a loose toilet lever. Both staff members confirmed these issues and acknowledged that there were no current work orders in the facility's maintenance system to address them. The facility's policy on Preventative Maintenance, dated August 2014, requires the Maintenance Department to maintain the physical plant in a safe and aesthetically pleasing condition, but this was not adhered to in this instance.
Failure to Implement Care Plan Interventions for Feeding and Pressure Injury Prevention
Penalty
Summary
The facility failed to implement care plan interventions for a resident's feeding assistance needs and pressure injury care and prevention. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, dysphagia, and unspecified glaucoma, required full feeding assistance and had a goal to consume 70-80% of meal intake. However, the Documentation Survey Report (DSR) for December 2024 showed missing meal intake amounts and staff signatures on specific dates, indicating a lack of proper documentation and potentially inadequate feeding assistance. Additionally, the resident had pressure injuries on the heel and sacro coccyx, with care plans indicating the use of pressure redistribution devices. The DSR for December 2024 and January 2025 lacked documentation of the presence of these devices and staff signatures on several shifts, suggesting that the interventions for pressure injury prevention were not consistently implemented. The Director of Nursing acknowledged the missing documentation, which should have been completed if the care was provided.
Improper Positioning of Wound Vacuum Pump
Penalty
Summary
The facility failed to position a wound vacuum pump in accordance with manufacturer guidance for a resident. The order summary report indicated a specific order for the application of a dressing to a wound on the resident's sacrum, which included the use of a Negative Pressure Wound Therapy (NPWT) system. During an observation, the NPWT device's pump was found sitting on the floor next to the resident's bed, with multiple cables and a tube in direct contact with the observer's feet. The manufacturer's guidance specified that the NPWT system and tubing should be positioned to avoid trip hazards and should be level with or below the wound whenever possible. The Director of Nursing agreed that the placement of the wound vacuum on the floor could pose a risk of tripping or disconnection.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
The facility failed to ensure that dietary staff wore appropriate hair restraints during meal service, as required by their policy. Observations on January 15, 2025, revealed that two staff members, identified as [NAME] #4 and [NAME] #5, were not wearing facial hair restraints while preparing and plating meals for residents. The facility's policy, effective February 2024, mandates that hair must be restrained or covered, but it was not adhered to during these observations. Interviews conducted with the involved staff and management highlighted a lack of clarity in the facility's policy regarding the use of facial hair restraints. [NAME] #5 believed that facial restraints were not necessary due to the perceived short length of his facial hair, while [NAME] #4 also did not wear a restraint, citing the facility's lack of requirement. The Dietary Manager admitted that the policy was unclear and stated that facial restraints were only required for facial hair over half an inch in length, although he was unaware of the actual length of the staff's facial hair. The Registered Dietician and the Administrator both confirmed that facial restraints should have been worn in the kitchen.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer their medication, as required by their policy. The policy mandates that residents who wish to self-administer medication must be assessed by a Licensed Nurse, and the assessment must be reviewed by the Interdisciplinary Team (IDT) for approval. The resident in question, who was admitted with a medical history of Parkinson's disease and type 2 diabetes mellitus, had a BIMS score indicating intact cognition. Despite this, there was no evidence in the medical record that the resident had been assessed for self-administration of medication. Observations revealed a bottle of multivitamins on the resident's bedside table, which the resident confirmed they were taking without an assessment or approval from the facility. The resident expressed a desire to continue self-administering their multivitamin. Interviews with facility staff, including an LVN and the DON, confirmed that the resident had not been assessed for self-administration and was not permitted to have the multivitamin in their room. The facility's failure to conduct the required assessment and obtain a physician's order for self-administration led to the deficiency.
Inaccurate MDS Assessment for Resident on Hospice Care
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, leading to a deficiency. The resident, who was admitted with a medical history of neurofibromatosis and was receiving palliative care, had a significant change in status MDS assessment that did not accurately reflect their hospice care status. The MDS indicated a Brief Interview for Mental Status (BIMS) score of 10, showing moderate cognitive impairment, but failed to document the resident's hospice care, despite the care plan and order recap report indicating hospice services were initiated. Interviews with facility staff revealed that the MDS Coordinator acknowledged the oversight and confirmed that the hospice care should have been coded in the MDS. The Director of Nursing emphasized the importance of MDS accuracy for reimbursement and meeting resident needs, while the Administrator highlighted that the MDS triggers quality measures for care planning. The responsibility for ensuring MDS accuracy was attributed to the MDS Coordinator, who admitted the error and the need for a modification to correct the assessment.
Failure to Resubmit Level I PASARR Screening
Penalty
Summary
The facility failed to resubmit a new Level I screening for a resident who remained in the facility beyond 30 days, as required by the preadmission screening and resident review (PASARR) program. The facility's policy, revised in May 2024, mandates that if a resident who was not initially screened remains in the facility longer than 30 days, a Level I screening should be conducted and referred to the appropriate state authority for a Level II PASARR evaluation if necessary. Resident #22, admitted on September 20, 2022, with a medical history of depression and anxiety disorder, did not have a new Level I screening completed after staying in the facility for more than 30 days. Interviews with facility staff revealed a lack of awareness and oversight regarding the requirement for a new Level I screening for Resident #22. The Assistant Director of Nursing was unaware of the need for a new screening, and the Director of Nursing acknowledged that the screening should have been resubmitted after the resident's 31st day in the facility. The Administrator also confirmed that the screening was necessary but was not completed, indicating a lapse in following the facility's policy and state requirements.
Improper Medication Storage for a Resident
Penalty
Summary
The facility failed to ensure proper storage of medications for a resident, leading to a deficiency. Resident #129, who was admitted on 12/31/2024 with a medical history of Parkinson's disease and type 2 diabetes mellitus, was observed to have a bottle of multivitamins on their bedside table on multiple occasions. The resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, and had an order for a multivitamin to be taken once daily. Despite this, the multivitamin was not stored securely as required by facility policy. During observations on 01/14/2025 and 01/15/2025, the surveyor noted the multivitamin bottle on the resident's bedside table. The resident stated they took the multivitamin because it was all-natural and organic. On 01/16/2025, an LVN confirmed the presence of the multivitamin on the bedside table and acknowledged that the resident was not permitted to have it in their room. The facility administrator later stated that medications should be secured in the resident's bedside drawer after assessing the resident's ability to self-administer medication, which was not adhered to in this case.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the responsible party (RP) after a fall incident involving a resident. The resident, who was admitted with a primary diagnosis of general muscle weakness following a cerebral infarction, had intact cognition and was capable of making healthcare decisions. The resident's niece was designated as the decision maker or RP. On a specific date, the resident experienced an unwitnessed fall while attempting to self-transfer from a wheelchair to a bed, resulting in a skin tear on the right elbow. Although the physician was notified, the RP was not informed of the incident. During interviews and record reviews, it was confirmed that there was no documentation of notification to the RP, despite the facility's policy requiring such communication. The administrator suggested that verbal information might have been relayed to the RP, but this was not documented. The resident's Power of Attorney granted the RP full authority to manage healthcare decisions and receive notifications, emphasizing the importance of informing the RP about incidents affecting the resident's health and safety.
Failure to Assist Resident with Outside Medical Appointment
Penalty
Summary
The facility failed to assist a resident in making an outside appointment for a cataract evaluation as per the prescriber's order. The resident was admitted to the facility and had an order dated 11/1/23 for an evaluation at an ophthalmology clinic. During an interview on 4/15/24, the Administrator confirmed that the facility could not provide documentation showing that staff had attempted to make the appointment before the resident was discharged. The job description for the Social Services Assistant included coordinating and setting up such appointments, and the facility's policy on Resident Rights emphasized the resident's right to access services outside the facility.
Failure to Maintain Accounting System for Resident's Personal Funds
Penalty
Summary
The facility failed to maintain a system for a full and complete accounting and management of personal funds entrusted to the facility for one of the sampled residents. Resident 1, who was admitted with multiple fractures in the right ribs and had intact cognitive abilities, left $300 with the facility's Social Services Assistant (SSA) for purchasing items. However, there was no signed agreement or accounting statement provided to Resident 1 regarding the funds left in the care of the facility. During an observation and interview, it was found that the SSA kept Resident 1's money in a locked safety deposit without any accounting system. The Director of Social Services (DSS) confirmed the absence of a system to account for the cash left by residents. The Administrator also stated that they only have accounting for trust funds but not for cash left by residents. The facility's policy and procedure indicated that a full accounting of all disbursements made to or on behalf of the resident should be maintained, which was not followed in this case.
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 41 citations issued within 25 miles in the last 12 months — 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 Santa Barbara
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Channel Islands Post Acute | 3.4 mi | ★★★★★ | 3 | 0 |
| Valle Verde Health Facility | 3.5 mi | ★★★★★ | 7 | 0 |
| Samarkand Skilled Nursing Facility | 4.6 mi | ★★★★★ | 4 | 0 |
| Mission Park Healthcare Center | 4.6 mi | ★★★★★ | 0 | 0 |
| The Californian | 5.1 mi | ★★★★★ | 0 | 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 June 2026) and official state health department websites.