Buena Vista Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the immediate environment of 5 of 6 sampled residents (Residents 18, 16, 24, 3, and 21) reviewed for environment, was free from visible clinical information prior to assessing if it violated the resident's privacy. Findings included . <Resident 16> An observation and interview in Resident 16's room on 02/11/2025 at 09:09 AM showed signage on the overhead light that read, 2 per FWW [ a walker], Do not bend more than 90 degrees, and Please float right heel. Additionally observed was a laminated sign on the wall and under the overhead light for posterior hip precautions. Review of a 01/27/2025 admission assessment showed the staff assessed Resident 16's cognition was intact. Resident 16 had a roommate. When asked about knowledge of the signage with care directives, Resident 16 stated, I don't know what they are. I can't read them anyway. I don't know what they say. <Resident 24> An observation and interview in Resident 24's room on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to identify what information was conveyed to the hospital at the time of transfer for 2 of 2 sampled residents (Residents 16 and 24) reviewed for hospitalizations. This failure placed the residents at risk for a disruptive and ineffective transition from the facility to the hospital setting. Findings included . <Resident 16> Review of a 01/17/2025 progress note showed Resident 16 experienced a change in condition which required a transfer to the hospital. Review of the medical record showed no documentation the facility communicated to the hospital basic information of the resident's status necessary for a safe transition of care, such as contact information for their provider, family or representative, code status, advanced directives, plan of care and treatment, current medications and the reason for the hospital transfer, as required. <Resident 24> Review of a 6/10/2024 progress note showed Resident 24 experienced a change in condition which required a transfer to the hospital. Review of the medical record showed no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop the care plans for 2 of 12 sampled residents (Residents 16 and 24) whose care plans were reviewed. This failure placed the residents at risk for inadequate care and a diminished quality of life. Findings included . <Resident 16> Observations on 02/11/2025 at 8:55 AM, 02/12/2025 at 8:49 AM, 11:18 AM, and 2:47 PM, and 02/13/2025 at 8:32 AM, showed Resident 16 had an abductor wedge between their legs. An abductor wedge helped to stabilize the hip joint after hip surgery and reduced this risk of the hip joint dislocating. Review of Resident 16's care plan and February 2025 Treatment Administration Record showed no directions to the staff for the use of the abductor wedge. The above information was shared with Staff C, Minimum Data Set Coordinator/Registered Nurse (RN) on 02/13/2025 at 11:46 AM. Staff C acknowledged Resident 16's care plan did not include the direction to the staff to use the abductor wedge and stated, It should include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide grooming for 1 of 3 sampled residents (Resident 35), reviewed for activities of daily living (ADLs). This failure placed the resident at risk for poor personal hygiene and a diminished quality of life. Findings included . According to the 01/23/2025 Baseline care plan, Resident 35 required assistance from staff to complete ADLs such as personal hygiene, dressing, and grooming. Observations of Resident 35 were made while they were sitting in their wheelchair in their room and during group activities with the same clothes on, long facial hair and long jagged fingernails, were made on 02/11/2025 at 09:32 AM, 02/12/2025 at 09:51 AM, and 02/13/2025 at 08:56 AM and again at 02/13/2025 at 01:24 PM In an interview on 02/12/2025 at 09:51 AM, Resident 35 stated they had been in the same clothes for three or four days, since their shower on 02/09/2025. They further stated that the clothes belonged to the facility because their clothes were being laundered at the time of their shower. Resident 35 said their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to coordinate hearing services for 1 of 1 sampled resident (Resident 24) reviewed for communication. This failure placed the resident at risk for unmet needs and a diminished quality of life. Findings included . Review of a nursing admission evaluation showed Resident 24 admitted to the facility on [DATE]. The evaluation showed the staff assessed Resident 24 was hard of hearing in both ears. An observation on 02/10/2025 at 3:06 PM showed Resident 24 in bed. Resident 24 had difficulty hearing and answered written questions. A Caption Telephone (CapTel) was on the bedside table to the resident's right side. The CapTel transcribed what the caller said into written words. Captions can be read if the resident cannot hear what the caller was saying over the telephone. An observation on 02/11/2025 at 11:15 AM showed Staff E, Licensed Practical Nurse (LPN), preparing medications to administer to Resident 24. Staff E stated that they when they had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to serve food in accordance with professional standards for food service safety when staff were observed serving food without using appropriate hand hygiene for 1 of 3 dining observations. Staff were also observed carrying cups with bare hands touching the rims of drinking surfaces. This failure increased the resident's risk for food borne illness. Findings included . Review of the facility's policy titled, Handwashing/Hand Hygiene, dated May 2015, showed use of an alcohol-based hand rub before and after direct contact with residents, before and after handling food and before and after assisting a resident with meals. During the lunch time dining observation on 02/10/2025 at 11:18 AM, staff J, Nursing Assistant, was observed bringing residents into the dining room, moving in and out of the kitchen without performing hand hygiene. Staff J was also observed serving beverages with bare hand contact touching the rim of the cups without performing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to implement bowel management protocol when indicated for 2 of 5 sampled residents (Resident 26 and 31), reviewed for constipation. In addition, the facility failed to monitor and implement interventions for edema (swelling) management for 1 of 3 sampled residents (31), reviewed for edema. These failures placed residents at risk for complications, worsening conditions, and diminished quality of life. Findings included . Review of the facility policy titled, Bowel Protocol, revised 03/2018, documented nursing staff was to review a resident's bowel monitor daily. The policy instructed nursing staff to implement the bowel program if a resident did not have a bowel movement (BM) for three days. The policy showed nursing staff was to administer Milk of Magnesia (MOM) on day four, a laxative suppository was to be administered the next shift if no results from MOM, an enema was to be administered the next shift if no results from the suppository, and the provider was to be notified if there were no results from the enema. Bowel…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure staff followed enhanced barrier precautions, cleaned mechanical lifts after usage, and performed hand hygiene when indicated during the meal service and wound care. These failures placed residents at risk of transmission of communicable diseases and/or healthcare associated diseases, and diminished quality of life. Findings included . Review of the facility policy titled, Handwashing/Hand Hygiene revised 03/2018, showed hand hygiene was the facilities primary means to prevent the spread of infections. The policy instructed staff to perform hand hygiene with alcohol-based hand rub or soap and water before and after direct contact with residents; before performing any non-surgical invasive procedure; before and after handling an invasive device; before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care; after contact with object in the immediate vicinity of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to assess and care plan for safe self-medication administration for 1of 1 sampled residents (Resident 28), reviewed for medication administration. This failure placed residents at risk of medication errors, adverse side effects, and diminished quality of life. Findings included . Review of the facility policy titled, Self-Administration of Medication revised 09/2017, documented if a resident desired to self-administer medications the facility would complete a self-medication evaluation before the resident was able to self-administer medications. The assessment would be reviewed quarterly or upon a change of condition. The policy instructed nursing staff to obtain a provider order for self-administration for the specific medications, initiate a self-medication administration care plan, initiate a bedside self-medication administration record, determine whether medication would be stored at the nursing station or at bedside, and obtain and initiate proper safety mechanisms if medications were to be stored at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide assistive cups as care planned for 1 of 3 sampled residents (Resident 17) reviewed for activities of daily living (ADL's). This failure placed the resident at risk for continued swallowing difficulties and decreased fluid intake. Findings included . A review of the 03/04/2024 comprehensive admission assessment documented Resident 17 had diagnoses which included kidney stones and an enlarged prostate. The resident had moderate cognitive impairment and required set-up/clean-up assistance for eating. Resident 17 had loss of food from their mouth when eating and held food in their mouth or cheeks after eating. The baseline care plan dated 02/27/2024 showed Resident 17 required set-up/clean-up assistance for eating and was to use a sippy cup (has a spout and two handles to aid drinking and prevent spillage) for all liquids and could also use a straw. The nutritional care plan documented Resident 17 was to have aspiration precautions (interventions that prevented inhaling foods and drinks when eating such as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure nail care was provided for 2 of 3 sampled residents (Resident 17 and 29) reviewed for activities of daily living (ADLs). Specifically, two residents used their fingers to help scoop food onto their eating utensils and to pick up food from their plates and their nails had dark matter under them. This failure placed the residents at risk of contracting bacterial and diarrheal illnesses. Findings included . <Resident 17> A 03/04/2024 comprehensive admission assessment documented Resident 17 had diagnoses including spinal stenosis (narrowing of the spaces in the bones that can put pressure on the spinal cord) and enlarged prostate requiring indwelling urinary catheter. Resident 17 was moderately impaired cognitively, required set-up/clean-up assistance for eating and personal hygiene and lost food from their mouth when eating and drinking. The care plan dated 02/27/2024 instructed staff to provide set-up/clean-up assistance to the resident for eating and personal hygiene, keep fingernails short to protect…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment was maintained in a clean manner for 1 of 1 sampled residents (Resident 26) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included . Per the 02/15/2024 quarterly assessment, Resident 26 had diagnoses which included pericardial effusion (the buildup of extra fluid in the space around the heart), sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and needed oxygen due to those conditions. Review of the physician orders documented on 08/15/2023, the resident had been prescribed oxygen to be used as needed to maintain oxygen saturations greater than 90 percent, due to the diagnoses listed above. The orders also documented to change the filter monthly and to change the oxygen tubing as needed if damaged or unable to have been cleaned. Review of Resident 26's care plan found there was no respiratory care plan in place to instruct staff what the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure dietary staff had the proper qualifications. Failure to ensure the dietary manager had the proper certification placed all residents at risk for nutritional deficits, unmet nutritional needs, and diminshed quality of life. Findings included In an interview on [DATE] at 1:32 PM, Staff Q, Dietary Manager, stated their license had expired and they were in the process of getting certified as a dietary manager. On [DATE] at 9:32 AM, Staff A, Administrator, confirmed the Dietary Manager for the facility was not certified as a dietary manager. Reference (WAC) 388-97-1160 (1)

Based on observation and interview, the facility failed to maintain appropriate dishwasher temperatures, date and dispose of expired foods and failed to prepare food in a sanitary manner. These failures placed the residents at risk for food borne illnesses and decreased quality of life. Findings included . <Dishwasher temperatures> During an observation of the kitchen on 04/11/2024 at 12:42, Staff Q, Dietary Manager, stated the dishwasher was a low temperature dishwasher, which must sanitize the dishes at 120 degrees or above. Staff Q stated that maintenance was informed each time the dishwasher was below 120 degrees, and the temperature was fixed. Staff Q was unable to provide documentation showing the temperature had been fixed and what the new temperature was afterward, and the maintenance person was on vacation. During an observation on 04/11/2024 at 12:50 PM, Staff R, Dietary Aide, had ran two loads of trays though the dishwasher and the trays reached a temperature of 117 degrees, not 120 degrees as required. Staff R had put those trays away and continued washing the next load.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.