Buckner Westminster Place

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that:1. Meat thawing in the kitchen sink was not fully submerged, nor did it have water continuously running to agitate the surface of the water.2. Cooked chicken stored in the refrigerator was not labeled and dated.3. Buffet lids were stored directly on the floor. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident's drug regimen was free from PRN orders for psychotropic drugs were limited to 14 days for 1 of 9 residents reviewed for unnecessary psychotropic drugs (Resident #5). The facility failed to place a 14-day end date to Resident #5's psychotropic medication prescribed as needed for Xanax tablet .25 milligrams. This failure could put residents at risk of psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care were provided with such care, consistent with professional standards of practices for 1 of 16 residents (Resident #11) reviewed for respiratory care. The facility failed to cover nasal cannula tubing with a bag and prevented the oxygen tubing from floor contact for Resident #11. The facility failed to ensure Resident #11's oxygen humidifier bottle and tubing were changed weekly. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 19 residents (Resident #7) reviewed for medication storage. The facility failed to securely store wound care chemicals for Resident #7 on 7/13/26-7/14/26. This failure could place residents at risk for adverse reactions, risk of having access to unauthorized medication and/or lead to harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 residents (Resident #11) reviewed for infection control practices. 1. The facility failed to ensure CNA B donned her gown prior to providing incontinent care for Resident #11 on enhanced barrier precautions on 7/13/26. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills set to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 3 of 20 kitchen staff (Cook A, Waitstaff B, and [NAME] C) reviewed for qualified dietary staff . The facility failed to ensure [NAME] A, Waitstaff B, and [NAME] C met the requirements for food handling by obtaining a current and valid Food Handler's Certificate. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food borne illnesses.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 8 residents (Resident #12 and Resident #16) reviewed for care plans. 1. The facility failed to develop a person-centered care plan for Resident #16's planned weight loss of 8.35 % from 5/7/2025 to 6/1/2025 and implement recommendations for multivitamin with minerals daily and supplemental Ensure. 2. The facility failed to ensure Resident #12's comprehensive care plan was developed to address nectar thickened liquids as prescribed by the physician . [...]

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement and volunteers, consistent with their expected roles for 1 of 15 employees (Director of Culinary Services) reviewed for training. The facility failed to ensure the Director of Culinary Services received training on the topics of HIV, restraint reduction, fall prevention, resident rights, behavioral health, and infection prevention and control. This failure could place residents at risk for unmet needs.

Inspectors wroteBased on interview and record review the facility failed to provide training to their staff that at a minimum educated staff on activities that constituted abuse, neglect, exploitation, and misappropriation of resident property and procedures for 1 of 15 employees (Director of Culinary Services) reviewed for staff training. The facility failed to ensure the Director of Culinary Services received abuse training. This failure could place residents at risk of abuse, neglect, and exploitation and a poor quality of care.

Inspectors wroteBased on interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for one (Resident #1) of five residents reviewed for a change of condition. The facility failed to notify the physician of changes in surgical incision for Resident #1 after finding surgical incision dressing saturated on 9/14/2024 and 9/16/2024. The facility failed to notify the physician of a change in surgical incision dressing saturation for Resident #1 resulting in infection identified on post-op visit on 9/25/2024 requiring oral antibiotic treatment. The noncompliance was identified as Past Non-Compliance (PNC). The non-compliance began on 9/13/2024 and ended on 9/27/2024. The facility had corrected the noncompliance before the investigation began. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 2 (Resident #1) residents reviewed for surgical incision. The facility failed to clarify and obtain surgical incision care orders for Resident #1 upon admission on [DATE]. The facility failed to clarify hospital discharge orders for surgical incision site care upon admission on [DATE] for Resident #1. The facility failed to assess and identify a change in condition for Resident #1's surgical incision site to left hip on 9/14/2024 resulting in an infection requiring antibiotic on follow-up appointment with surgeon on 9/25/2024. The noncompliance was identified as Past Non-Compliance (PNC). The non-compliance began on 9/13/2024 and ended on 9/27/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 17 residents reviewed for environment. (Resident #1) The facility failed to ensure Resident #1's air vent and closet was free from a black substance. The facility failed to repair the open space where the airconditioning unit was. The facility covered the open space with cardboard and tape. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Paint, primer, WD 40 and GOO gone stored near dry food storage. 2. Sanitizer sprayed on surface and not allowed to dry prior to setting cutting board and preparing food. 3. Improperly secured hair from kitchen staff member. These deficient practices could place residents who received meals from the kitchen at risk for chemical contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs were provided for 1 of 17 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 had a call light within reach. This failure could place residents at risk of injury that could lead to possible falls, major injuries, hospitalization, and unmet needs. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 laundry rooms. ([NAME] House laundry room) The facility failed to ensure soiled laundry was properly bagged in 1 of 3 laundry rooms. These failures placed residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 of 3 residents reviewed for pharmacy services (Resident #'s 1 and 2). 1. The facility failed to provide 7 (daily) doses of Resident #1's physician ordered Enoxaparin/Lovenox (a blood thinner to prevent blood clots) between the dates of 2/15/24 - 2/21/24. 2. The facility failed to provide 11 (weekly) doses of Resident #2's physician ordered Bydureon (treats Type 2 Diabetes and controls blood sugar levels) between the dates of 12/11/23 - 2/13/24. 3. Staff falsified documentation indicating they had administered Lovenox for Resident #1 and Bydureon for Resident #2 when those medications were not available in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remained free of any significant medication errors for 2 of 3 residents reviewed for medication errors (Resident #'s 1 and 2). 1. The facility failed to provide 7 doses of Resident #1's physician ordered Enoxaparin/Lovenox (a blood thinner to prevent blood clots) between the dates of 2/15/24 - 2/21/24. 2. The facility failed to provide 11 doses of Resident #2's physician ordered Bydureon (treats Type 2 Diabetes) between the dates of 12/11/23 - 2/13/24. The noncompliance was identified as PNC. The IJ began on 12/11/23 and ended on 2/29/24. The facility had corrected the noncompliance before the survey began. [...]