Buchanan Place

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to submit a Pre-admission Screening and Resident Review (PASRR) timely after a new mental health diagnosis for 2 residents (Resident #4 and Resident #79) of 11 residents reviewed for PASRR.

Inspectors wroteBased on facility policy review, medical record review, observations and interviews, the facility failed to obtain a Physician's Order for 1 resident (Resident #26) of 2 residents reviewed for Continuous Positive Airway Pressure (C-PAP) use.

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility staff failed to perform appropriate hand hygiene when serving residents' meal service for 4 residents (Residents #75, # 74, #78, and #6) in 1 of 2 dining areas observed for meal tray distribution, and failed to ensure C-PAP equipment was kept in a clean and sanitary condition for 1 resident (Resident #26) of 2 residents reviewed for C-PAP.

Inspectors wroteBased on facility policy review, facility investigation documentation review, medical record review, observations, and interviews, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 resident (Resident #15) of 22 residents reviewed for abuse. Resident #17 struck Resident #15 on 4/20/2025 and again on 5/7/2025.

Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to implement the comprehensive care plan for 1 resident (Resident #15) for 22 residents reviewed for care plans.

Inspectors wroteBased on facility policy review, medical record review, facility documentation review, observation and interviews, revealed the facility failed to ensure 1 resident (Resident #6) received adequate supervision to prevent elopement (a situation which involves a resident leaving the premises or safe area without necessary supervision) from the premises of 7 sampled residents reviewed for accidents. On 6/18/2023, at approximately 4:15 PM, the facility staff were unable to locate Resident #6. The resident remained out of staff supervision for 1 hour and 12 minutes. [...]

Inspectors wroteBased on review of facility policies, medical record reviews, review of facility investigations and interviews, the facility failed to maintain controls (chain of custody) on narcotic inventories which resulted in diversion of narcotic stocks for 3 of 20 residents (Residents #4, #9, and #35) of 20 residents sampled for misappropriation, of 35 sampled residents.

Inspectors wroteBased on facility policy review ,medical record review, facility documentation review and interviews, the facility failed to protect 1 resident (Resident #12) from abuse of 19 residents reviewed for abuse.

Inspectors wroteBased on facility policy review, facility memo review, observation, and interview, the facility failed to separate resident and staff food items in 2 of 2 resident nourishment rooms, failed to date and label opened and/or prepared food items in 2 of 2 resident nourishment rooms, and failed to maintain a sanitary environment in 2 of 2 resident nourishment rooms possibly affecting 86 of 90 residents.

Inspectors wroteBased on review of the facility's Resident Fund Statement, medical record review, and interview, the facility failed to ensure the trust fund accounts for 2 residents (#50 and #78) of 53 residents with trust fund accounts reviewed did not exceed the $2000.00 Supplemental Security Income (SSI) resource limit.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to implement a comprehensive care plan for Peripherally Inserted Central Catheter (a thin, long tube inserted into a vein in the arm for delivering medications and fluids) (PICC) care for 1 resident (Resident #5) of 19 residents reviewed for care plans.

Inspectors wroteBased on the facility policy, medical record review, observation, and interview, the facility failed to follow physician's orders for 2 residents (Residents #5 and #67) of 19 residents reviewed for physician's orders.

Inspectors wroteBased on facility policy review, facility fall investigation review, observation, and interview, the facility failed to ensure the correct mattress was placed on a bed frame resulting in a fall for 1 resident (#183) of 3 residents reviewed for falls.

Inspectors wroteBased on review of facility Nurse Aide (NA-a noncertified employee performing direct resident care without completing the certification and competency evaluation) competencies and interviews, the facility failed to ensure employees working after June 7, 2022, the end of the COVID-19 Emergency Declaration Blanket 1135 Waivers, were actively seeking certification to become a Certified Nurse Aide (CNA) either through this challenge process or had enrolled in a traditional CNA Training program (NAT) for 4 NA employees (#1, #2, #3, #4) of 4 NA hired by the facility.

Inspectors wroteBased on facility policy review, facility documentation review, medical record review, observation, and interview, the facility failed to ensure 3 of 38 staff followed infection control practices for 2 residents (Resident #5 and Resident #22) of 3 residents reviewed for transmission based precautions, and failed to ensure proper cleaning procedures were followed in 1 of 4 rooms reviewed for housekeeping services.

Inspectors wroteBased on medical record review, review of facility policy, observation, and interview, the facility failed to check the gastric tube placement for 1 resident (#24) of 1 resident observed for medication administration by gastric tube; and failed to follow Physician's Order for tube feeding for 1 resident (#43) of 6 residents observed for enteral tube feeding.

Inspectors wroteBased on review of the facility policy, medical record review, observation and interview the facility failed to maintain infection control practices during tracheostomy (surgical formation of an opening into the trachea through the neck to allow passage of air) care for 1 resident (#69) of 1 resident observed for tracheostomy care.

Inspectors wroteBased on medical record review and interview the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, a final summary of the resident's status at the time of discharge for 3 residents (#92, #94, #248) of 6 residents reviewed for transfer/discharge requirements.