Average — CMS composite of the measures below.
A standard survey is most likely before 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 Vida Nursing And Rehab Odessa during CMS and state inspections, most recent first.
A resident with type 2 diabetes did not receive prescribed glimepiride for five days because the medication, supplied by the family, was lost after delivery to the facility. Medication aides documented the drug as unavailable and notified charge nurses, but there was no clear follow-up or retrieval from the E-kit. The DON was unaware of the missed doses until informed by surveyors, and facility policy for medication administration and handling of unavailable medications was not effectively followed.
A resident with severe cognitive impairment, hemiplegia, and a history of falls was regularly observed using a Geri chair for mobility, but the care plan did not include any focus, goals, or interventions related to its use. Staff interviews confirmed the necessity of the Geri chair due to the resident's physical limitations, yet the omission in the care plan was acknowledged by multiple staff members. The facility's policy required comprehensive care planning, but the resident's needs for Geri chair mobility support were not documented.
A resident with a gastrostomy tube did not receive required physician orders for tube flushing and site care after tube feedings were discontinued. Nursing staff and the DON were unaware that orders had lapsed, resulting in no tube maintenance or site care being provided for an extended period, despite the resident's ongoing need for tube patency and infection prevention.
Surveyors found that insulin pens and vials on multiple medication carts were either not dated upon opening or remained in use past their expiration period, contrary to facility policy and professional standards. Nursing staff and leadership confirmed that it was the responsibility of each nurse to check for expired or undated insulin, but these checks were not consistently performed, leading to expired and undated insulin being available for administration.
A nurse failed to wear a gown, as required by enhanced barrier precautions, while administering IV medication to a resident with a central line and an unhealed pressure injury. Although the care plan and posted instructions specified the need for both gloves and a gown for high-contact activities, only gloves were used. The nurse was unsure of the PPE requirements, and facility leadership confirmed that proper PPE should have been used according to policy.
A resident with Alzheimer's disease and paraplegia, fully dependent for transfers, was moved from bed to wheelchair by a CNA and LVN without the use of a gait belt, contrary to facility policy and the resident's care plan. Instead, staff lifted the resident by her underarms and the back of her pants, and both later acknowledged the omission of the gait belt. The DON and Administrator confirmed this was not in line with required procedures.
A resident with a history of amputation, dementia, and diabetes suffered second-degree burns after using a lighter to remove a tight gauze bandage, due to delayed staff response and the facility's failure to enforce its policy prohibiting lighters in resident rooms. Multiple residents were found with lighters, and staff interviews revealed inconsistent retrieval of lighters after smoke breaks and a lack of a written smoking procedure, leading to inadequate supervision and accident hazards.
A resident with a history of Covid-19 and other health issues received incontinence care from two CNAs who failed to follow proper infection control protocols. The CNAs did not change gloves or perform hand hygiene as required, leading to potential cross-contamination. Despite having received training, the CNAs acknowledged their mistakes, and the DON confirmed awareness of the issue.
A long-term care facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for three residents. Two residents received Metoprolol Tartrate despite their blood pressure being below the prescribed threshold, and another resident was given short-acting insulin without clear parameters for when to hold the medication. The errors were acknowledged by the DON and a Regional Consultant, highlighting a lack of specific guidelines and potential confusion among nursing staff.
A resident with severe cognitive impairment and limited mobility suffered leg injuries due to inadequate padding on her wheelchair. The facility failed to document or investigate the wounds, which were discovered by a state surveyor. The DON and Treatment Nurse were unaware of the injuries, and the care plan did not address the risk of injury from the wheelchair.
A CNA failed to follow proper infection control procedures during incontinent care for a resident with bladder incontinence. The CNA did not change gloves or perform hand hygiene after handling soiled materials and before continuing care, which could lead to cross-contamination. Interviews with the CNA, DON, and Administrator confirmed the lapse in protocol adherence, attributing it to possible nervousness.
Failure to Administer Prescribed Diabetes Medication Due to Lost Supply and Communication Breakdown
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with type 2 diabetes, morbid obesity, and Alzheimer's disease. The resident was prescribed glimepiride, an oral medication for diabetes management, which was not administered for five consecutive days as documented in the Medication Administration Record (MAR). The MAR indicated the medication was unavailable on those days, and multiple medication aides confirmed they did not administer the drug due to its unavailability. The resident's responsible party reported that a 90-day supply of glimepiride had been delivered to the facility, but staff lost the medication, and the facility did not follow through with obtaining a new supply as promised. Interviews with medication aides revealed that they notified charge nurses about the missing medication and that it was common practice to retrieve medications from the emergency kit (E-kit), but it was unclear if this was attempted. The aides could not recall which charge nurse was informed, and there was no documentation of further action to secure the medication from the E-kit or other sources. The responsible party was told by staff that the medication was in stock and being administered, but this was not the case according to the MAR and staff interviews. The Director of Nursing (DON) was unaware that the resident had missed five days of glimepiride until informed by the surveyor. The DON confirmed that a staff member had signed for the medication delivery, but the medication could not be located. The facility's policy required medications to be administered as prescribed and outlined procedures for handling unavailable medications, but these procedures were not effectively followed in this instance, resulting in the resident missing multiple doses of a critical medication.
Failure to Develop and Implement Comprehensive Care Plan for Geri Chair Use
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident who required the use of a Geri chair for mobility. Despite multiple observations of the resident using a Geri chair throughout the facility, the care plan did not include any documented focus, goals, or interventions related to the use of this equipment. The resident's electronic records indicated significant medical needs, including nontraumatic intracranial hemorrhage, right side hemiplegia, muscle weakness, and severe cognitive impairment, all of which necessitated specialized mobility support. Interviews with facility staff, including the Director of Rehab, Regional Nurse Consultant, LVN, MDS Coordinator, and DON, confirmed that the resident regularly used a Geri chair due to poor trunk control and a history of falls from bed and wheelchair. Staff acknowledged that the Geri chair was essential for the resident's mobility and safety, and that its use should have been included in the care plan. The Director of Rehab noted that attempts to use a standard wheelchair were unsuccessful due to the resident's physical limitations, and the Regional Nurse Consultant stated that Geri chairs should be care planned as part of the resident's mobility needs. The facility's own policy required the development and implementation of a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes to address identified needs. However, the care plan for this resident did not reflect the use of the Geri chair, and staff interviews revealed a lack of clarity regarding responsibility for updating care plans. This omission could result in staff not being aware of the resident's mobility needs and the equipment required for their care.
Failure to Maintain Physician Orders and Care for Resident with Gastrostomy Tube
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications for a resident with a gastrostomy feeding tube. Specifically, after all enteral feed orders were discontinued, the resident continued to have a gastrostomy tube in place but did not have physician orders for the volume, frequency, and type of flush to maintain tube patency, nor for the frequency of cleaning and care of the tube site. As a result, no enteral feeding care, including flushes or site care, was administered for an extended period while the tube remained in place. The resident involved was an older female with diagnoses including protein-calorie malnutrition, dysphagia, Parkinson's disease, and abnormal weight loss. She had moderate cognitive impairment but was able to understand and be understood. Although she required tube feeding due to dysphagia, she chose to eat by mouth and was not receiving nutrition via the tube during the period in question. The care plan indicated the need for daily cleansing of the insertion site and monitoring for infection or tube dysfunction, but these interventions were not carried out due to the lack of physician orders. Interviews with nursing staff, the DON, and the resident's physician confirmed that nurses were responsible for obtaining and maintaining appropriate physician orders for tube care and flushing. The DON and staff were unaware that the orders had been discontinued, and the facility's policy did not specify requirements for flushing or cleaning the insertion site. The absence of orders and care placed the resident at risk for tube obstruction, malfunction, and infection, as noted by the staff and physician during interviews.
Failure to Properly Label and Remove Expired Insulin from Medication Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals, specifically insulin pens and vials, were properly labeled and stored according to professional standards. During observations of three medication carts, surveyors found insulin pens that had been opened and not dated, as well as insulin pens that remained in use beyond their manufacturer-recommended expiration period after opening. Nursing staff present during the inspections acknowledged that the insulin pens should have been removed once expired and that opened vials should have been dated. The staff indicated that it was each nurse's responsibility to check their assigned medication carts for expired or undated medications, but these checks were not consistently performed. Interviews with the DON and Administrator confirmed that the facility's expectation was for nursing staff to date insulin products upon opening and to discard them after the recommended period, typically 28 to 30 days. Facility policy also required dating insulin pens when placed into use and discarding them after 28 days at room temperature. The deficiency was attributed to nursing staff failing to inspect their medication carts as required, resulting in expired and undated insulin remaining available for resident use.
Failure to Use Required PPE During Central Line Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to follow the facility's infection prevention and control program during the administration of IV medication to a resident with a central line. The resident, who had diabetes with a foot ulcer and an unhealed pressure injury, was on enhanced barrier precautions (EBP) due to the presence of a central line and risk of infection. The resident's care plan and posted instructions outside the room specified that gloves and a gown were required for high-contact activities, including central line care. During an observed medication administration, the nurse sanitized her hands, donned gloves, and administered the IV medication but did not wear a gown as required by EBP protocols. When questioned, the nurse expressed uncertainty about the need for a gown during IV medication administration and indicated she was unaware of other staff using gowns for similar procedures. The Director of Nursing and the Administrator both confirmed that the expectation was for staff to use appropriate PPE, including gowns, when caring for residents on EBP with central lines. Facility policy also required the use of gloves and gowns for high-contact activities involving indwelling medical devices. The failure to adhere to these protocols was identified through observation, interview, and record review.
Failure to Use Gait Belt During Dependent Resident Transfer
Penalty
Summary
Staff failed to provide adequate supervision and assistance devices during a transfer for a resident with Alzheimer's disease and paraplegia, who was fully dependent on staff for transfers. The resident's care plan specified that two staff members were required for assistance and that a gait belt should be used during transfers. However, during an observed transfer, a CNA and an LVN moved the resident from her bed to her wheelchair by grabbing her under the arms and by the back of her pants, without using a gait belt. The resident did not appear to bear weight during the transfer, as her legs were partially contracted. Interviews with the involved staff revealed that both the CNA and LVN acknowledged they should have used a gait belt but failed to do so—one citing forgetfulness and the other a lack of immediate availability. The DON and Administrator confirmed that facility policy required the use of a gait belt for such transfers and that the method used was not safe or in accordance with policy. Review of the facility's policy further confirmed that a gait belt was required for safe transfers involving dependent residents.
Failure to Prevent Accident Hazards Related to Smoking Paraphernalia
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards by allowing multiple residents to possess unauthorized lighters, despite a policy prohibiting such items in resident rooms. Five residents were found to have lighters in their possession, and staff interviews revealed that there was no written procedure for handling smoking paraphernalia. Staff often handed lighters to residents during smoke breaks and did not consistently retrieve them afterward, resulting in residents retaining lighters in their rooms. Several staff members and residents confirmed that lighters were not always collected after use, and there was a general lack of clarity and enforcement regarding the facility's smoking policy and procedures. One resident, a female with a history of traumatic amputation, dementia, and diabetes, suffered second-degree burns to her right foot after using a lighter to burn a gauze bandage that was too tight. The resident had previously been assessed as safe to smoke unsupervised, with no cognitive impairment noted on her BIMS assessment. On the night of the incident, the resident requested assistance with her bandage, but staff response was delayed. During this time, the resident attempted to remove the bandage herself using a lighter, which resulted in the bandage and her foot catching fire. Staff responded to the fire, and emergency services were called, but the resident initially refused treatment. Interviews with staff and residents indicated that the facility's policy prohibiting lighters in resident rooms was not consistently followed. Staff admitted to not always retrieving lighters after smoke breaks, and residents reported frequently having lighters in their possession. The facility did not have a written smoking procedure, and staff were unclear about the process for supervising residents during smoke breaks and managing smoking paraphernalia. The lack of adherence to policy and absence of clear procedures directly contributed to the incident and the presence of accident hazards in the facility.
Removal Plan
- Resident was sent to the emergency department for assessment after initially refusing any treatment; placed on 1:1 observation; psychiatric services referral made.
- All other residents who smoke, including those discovered with cigarette lighters, had a skin assessment completed with no visible signs of injury related to cigarettes or lighters.
- Facility administrator, director of nurses, and regional compliance swept all resident rooms for items not allowed in resident's rooms and to check for cigarette lighters; removed offending items and completed a log of items found and removed.
- Facility administrator/DON/Compliance nurse will keep a log of any medications/items (including cigarette lighters) not allowed found at bedside during champion rounds; any items discovered will be reported to the DON/Administrator at the time of discovery.
- Regional Compliance Nurse in-serviced the DON and administrator on items not allowed; if a resident is found with a cigarette lighter, the item is to be removed from the room.
- Smoke breaks are to be supervised by facility staff assigned to scheduled smoke breaks; residents will not be given a lighter to keep during smoke break; staff will light the cigarette for the resident and return the lighter to the smoking lock box after use.
- A log will be placed in the lock box to verify the count of cigarette lighters at the start and end of the smoke break; facility staff education provided on the new process.
- Facility administrator, director of nursing, or compliance nurse will review the lighter log for discrepancies.
- Staff were given a copy of the new process and verbal checks by DON and compliance nurses are being conducted each shift to verify understanding.
- Regional Compliance Nurse educated the DON/Administrator that this incident and any other incident related to smoking paraphernalia (including cigarette lighters) to be reviewed monthly by the QAPI committee; Area Director of Operations or Regional Compliance Nurse will attend QAPI committee meetings and verify continued compliance.
- Nursing staff education was begun by the Director of Nurses to ask residents returning from being out of facility to smoke if they have cigarette lighters in possession; if found, re-educate and take items or return them to family; incidents to be reported to DON/Admin immediately.
- Facility staff have been given written fact sheets to keep with them during the learning process and verbal questioning is being done of three staff members at least 5 times weekly and PRN.
- Facility completed education/notification in form of an email to all RPs of residents with a list of items not allowed in residents rooms (including cigarette lighters) and the smoking policy; physical copy to be mailed out to resident RPs; for all future residents, list of items not allowed in room will be provided upon admission as part of the admission packet.
- Education/in-service begun for all staff by facility director of nursing to reiterate the policy of items not allowed in residents rooms (including cigarette lighters) and smoking policy, by phone, COVR, and in person; staff will not be able to return to work until education has been provided; signature or acknowledgement of this education will be confirmed by an audit list; monitored for continuous compliance including new hires.
- Facility provided a copy of list of items not allowed (including cigarette lighters) and the smoking policy to residents and kept a signed copy; residents unable to sign confirmed by two witnesses; signed copy scanned into resident's electronic medical record.
- A sign was placed at the front door of the facility with the items not allowed (including cigarette lighters) and the smoking policy for reference and education.
- The physical environment of all residents was observed (closet, nightstands, storage containers) to ensure no cigarette lighters were retained in their room by the facility administrator, director of nurses, and regional compliance nurse.
- MD was notified of IJ F689 Free of Accidents/Hazards/Supervision/Devices.
- All facility staff were educated by the director of nursing that no residents may be left alone on the smoking patio; staff are to light the resident cigarettes and return lighter to the receptacle for safe keeping; facility administrator will review the lighter logs for compliance.
- All in-service education will be completed by new hires at orientation and before assuming duties in the facility; verified by Administrator, Director of Nurses, or Regional Compliance Nurse.
- Facility department heads or weekend manager on duty will conduct champion rounds in every resident room and look for items not allowed per written company guidelines (including cigarette lighters); remove items if identified and report to DON/Administrator; monitoring to start.
- Regional Compliance Nurse will monitor during weekly visits and ask DON and Administrator what items are not allowed in residents room (including cigarette lighters) and what to do if any are identified; will be questioned about the smoking policy and any identified violations; monitoring to continue for at least 8 weeks and PRN thereafter.
- Administrator/DON will assess five resident rooms for posted items not allowed (including cigarette lighters), to ensure residents do not have any items not allowed in room.
- Regional Compliance Nurse will assess for compliance with posted items not allowed (including cigarette lighters) once weekly by verification of completion of facility assigned monitoring and visual verification of five rooms each week; monitoring to continue for at least 8 weeks and PRN thereafter.
Inadequate Infection Control During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A and CNA B during incontinence care for Resident #1. Resident #1, a male with a history of Covid-19, gangrene, and bilateral leg amputations, required substantial assistance with activities of daily living and was always incontinent of bowel and bladder. During an observation, CNA A and CNA B did not adhere to proper hand hygiene and glove-changing protocols while providing care. CNA A used visibly soiled wipes multiple times without changing gloves or performing hand hygiene before applying skin protector and handling a clean brief. Similarly, CNA B did not change gloves before assisting with the clean brief, contributing to potential cross-contamination. Interviews with CNA A and CNA B revealed that both had received infection control training but failed to follow the protocols during the observed care. CNA A acknowledged the mistake and attributed it to nervousness, while CNA B recognized the risk of infection due to improper glove use. The Director of Nursing (DON) confirmed awareness of the infection control concerns and stated that staff were expected to follow standard precautions, including handwashing and glove changes. The facility's infection control plan and perineal care policy outlined the necessary steps for maintaining a safe and sanitary environment, which were not followed in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for three residents. Resident #24, a male with a history of stroke and hypertension, received Metoprolol Tartrate despite his blood pressure being below the prescribed threshold. The medication was administered on an evening when his blood pressure was recorded at 98/61, contrary to the order to hold the medication if systolic blood pressure was less than 100 or heart rate was less than 60. The Director of Nursing (DON) acknowledged the error, attributing it to potential confusion among nurses due to differing parameters for different residents. Similarly, Resident #69, a female with hypertension, was administered Metoprolol Tartrate on two occasions when her blood pressure readings were below the prescribed threshold of 110 systolic. On 6/10/24 and 6/17/24, her blood pressure readings were 106/67 and 105/60, respectively, yet the medication was given. The DON confirmed these errors, noting that the medication should have been withheld according to the resident's specific parameters. Resident #43, a female with Type 2 Diabetes Mellitus, was administered short-acting insulin (Novolog) without clear parameters for when to hold the medication. On two occasions, her blood sugar levels were below 90, yet she received the insulin. The DON and a Regional Consultant acknowledged the lack of specific hold parameters for Novolog, which could lead to potential hypoglycemic events. The facility's policy required physician notification for medication errors, but there was no evidence of such communication in these cases.
Failure to Prevent Injury Due to Inadequate Wheelchair Padding
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents. Specifically, the facility did not properly pad a resident's wheelchair, which led to injuries on the resident's legs. The resident, who had severe cognitive impairment and required substantial assistance for activities of daily living, was at risk for developing pressure ulcers. Despite these risks, the care plan did not address the potential for injury from the wheelchair. Observations revealed that the resident had an open wound on her left calf, which was covered with saturated steri-strips, and another scabbed area below it. The Director of Nursing (DON) was unaware of these wounds until informed by the state surveyor. The Treatment Nurse, who was responsible for weekly skin assessments, was also unaware of the wounds and had not documented them. The nurse suggested that the injuries might have occurred during a transfer to or from the wheelchair, which had been wrapped with sheepskin to prevent such injuries. Interviews with the DON and the Treatment Nurse indicated a lack of communication and documentation regarding the resident's skin condition. The DON admitted that no investigation into the cause of the wounds had been conducted until the surveyor's discovery. The facility's policy required skin assessments for new admissions and residents returning from hospital stays, but there was no documentation of the wounds in the resident's records, including shower sheets and nurse's notes. The lack of documentation and communication contributed to the oversight of the resident's injuries.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during the provision of incontinent care to Resident #79. Resident #79, who was admitted with diagnoses of muscle weakness and reduced mobility, was observed to have bladder incontinence and required regular incontinent care. During the care process, CNA A did not adhere to proper hand hygiene and glove-changing protocols, which are critical to preventing cross-contamination and infection spread. CNA A initially washed his hands and donned gloves before starting the care. However, after wiping the resident's vaginal area and noticing the bed sheets were wet with urine, CNA A removed his gloves and left the room to get clean sheets. Upon returning, he put on a new pair of gloves without washing or sanitizing his hands. He continued with the care, applying skin protection ointment and assisting the resident with dressing and transferring to a wheelchair, all without changing gloves or performing hand hygiene. Interviews with CNA A, the DON, and the Administrator revealed an acknowledgment of the failure to follow proper infection control procedures. CNA A admitted to not washing or sanitizing his hands and not changing gloves at appropriate times, which could lead to cross-contamination. The DON and Administrator confirmed that the expected protocol was not followed, attributing the lapse to possible nervousness on the part of CNA A. The facility's policies on perineal care and infection control emphasize the importance of hand hygiene and glove changes, which were not adhered to in this instance.
What surveyors are citing around you — mapped
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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 48 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Odessa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Medical Resort | 1 mi | ★★★★★ | 0 | 0 |
| Parks Health Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Focused Care At Odessa | 4 mi | ★★★★★ | 12 | 0 |
| Sienna Nursing And Rehabilitation | 4.5 mi | ★★★★★ | 2 | 0 |
| Deerings Nursing And Rehabilitation, Lp | 5.1 mi | ★★★★★ | 1 | 0 |
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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.