Buena Vista Care Center: Pain Medication Withheld After Surgery - CA
The patient, identified in inspection records only as Resident 2, told inspectors she had received her last dose of pain medication at noon on June 27 at the hospital. She said a staff member at the nursing home told her the medication had not arrived yet. Her medical record confirmed it: nothing was given on June 27. The first dose did not come until 5:44 the following morning.
She had just had joint replacement surgery. She was fully alert. Inspectors noted her cognitive screening score was a 15 out of 15, meaning she understood exactly what was happening and could communicate it clearly. She told them her knee was aching.
Her physician had written orders for three levels of pain medication. For mild pain, two tablets of Acetaminophen every six hours as needed. For moderate pain, one tablet of Roxicodone every four hours. For severe pain, two tablets of Roxicodone every four hours. None of it was given on June 27. Not the over-the-counter option. Not the opioid. Nothing.
The Director of Nursing, interviewed by inspectors on August 14, confirmed that no pain medication was administered that day. She also confirmed that the Roxicodone was available the entire time, stored in the facility's secured emergency medication supply.
That detail is the center of the finding. The facility's own policy, reviewed by inspectors, stated that a licensed nurse should obtain ordered medication from the emergency supply when a medication is unavailable. The Roxicodone was not unavailable. It was in the building. The nurse's notes from June 27 at 1:20 p.m. documented that Resident 2 was already reporting knee pain at a level 3, described as aching. The medication that covered pain at that level was sitting in a locked cabinet nearby. Nobody retrieved it.
When Resident 2 finally received Acetaminophen the next morning, the record showed her pain had reached a level 4. There was no documentation that anyone followed up to see whether the medication worked.
The complaint inspection was conducted on August 14 and 20, 2025, roughly seven weeks after the incident. The violation was cited at a level of minimal harm or potential for actual harm, a designation that reflects how inspectors categorized the severity, not necessarily how the night felt to a woman lying in a post-surgical bed with an aching knee, waiting for medication she had been told was not there.
Federal inspectors cited the facility for failing to ensure pain management was provided. The finding covered one of two residents whose care was reviewed in the complaint inspection.
Buena Vista Care Center's own pain management policy, dated August 2025, states that the facility will ensure pain management is provided to residents who require it, consistent with the resident's goals and preferences. Resident 2's goal, stated plainly to the staff member who turned her away, was straightforward: she was in pain and needed medication.
She had to wait until the next morning to get it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Buena Vista Care Center from 2025-08-20 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Buena Vista Care Center in Santa Barbara, CA was cited for violations during a health inspection on August 20, 2025.
She said a staff member at the nursing home told her the medication had not arrived yet.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.