Buena Vista Care Center

Based on interview, facility document review, and facility P&P review, the facility failed to conduct a thorough abuse investigation for one of five sampled residents (Resident 1) as evidenced by: * The facility did not interview the other resident, Resident 3 who was mentioned on interview to have caused distress to Resident 1.

This failure posed the risk of not identifying if other residents were affected by the reported abuse allegation.Findings:

Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 9/2022 showed all allegations are thoroughly investigated.

Review of the facility's SOC 341 Report of Suspected Dependent Adult/Elder Abuse form dated 8/7/25, showed Resident 1 reported having problems with the other residents in the facility, including verbal abuse and physical altercations, such as being hit twice. Resident 1 reported he would sometimes miss breakfast due to conflicts with his roommate, who was described as rude and disruptive. Resident 1 expressed frustration with these living conditions and the behavior of others around him.

Review of the facility's 5-day investigation summary dated 8/8/25, showed the following investigation was completed:- the Administrator and DON interviewed Resident 1. Resident 1 mentioned having issues with Resident 3 in the past, but not anymore. Resident 1 was offered and refused a room change. - the SSD interviewed Resident 4. Resident 4 denied concerns with Residents 1 and 3 and denied abuse or care concerns.

Review of the facility's abuse allegation investigation showed only two residents were interviewed (Residents 1 and 4). Resident 3 was not interviewed regarding the alleged abuse. On 8/12/25 at 1335 hours, an interview and concurrent facility document review was conducted with the SSD.

The SSD stated Resident 1 reported not being compatible with Resident 3 two times in the past.

The SSD verified she participated in the investigation for Resident 1's allegation of abuse and was the designated staff to conduct resident interviews.

The SSD stated she only interviewed Resident 4 to ask him if there were any issues or concerns between Residents 1 and 3.

The SSD stated she did not interview Resident 3 because the Administrator instructed her to only interview Resident 4.

The SSD reviewed Resident 1's interview with the Administrator and DON.

The SSD verified Resident 3 should have been included in the resident interviews. On 8/12/25 at 1426 hours, an interview was conducted with the Administrator regarding the investigation of Resident 1's abuse allegation.

The Administrator stated both she and the DON interviewed Resident 1 and the SSD interviewed Resident 4.

The Administrator stated during the interview with Resident 1, Resident 1 brought up concerns with Resident 3, and stated Resident 1 had ongoing concerns with Resident 3 in the past, and brought it up again.

The Administrator stated they have talked to Resident 3 in the past for roommate compatibility issues.

The Administrator stated they overlooked interviewing Resident 3 because they had talked to him in the past.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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