Buckingham Valley Rehabilitation And Nursingcenter

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 26 sampled residents. (Resident 7) Findings include:Review of facility policy entitled, Resident Self-Administration of Medication, last reviewed January 20, 2025, revealed that a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The resident's preference will be documented on the appropriate form and placed in the medical record. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form which is placed in the resident's medical record. When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are…

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 clinical record review and staff interview, it was determined that the facility failed to implement a physician's order for one of 26 sampled residents. (Resident 4)Findings include: Clinical record review revealed that Resident 4 had diagnoses that included heart failure, diabetes disease, and chronic kidney disease. A physician's order dated March 25, 2025, directed staff to administer a medication (midodrine hydrochloride) three times a day for hypotension. The medication was to be held if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was greater than 120 millimeters of mercury (mm/Hg). Review of Resident 4's medication administration record revealed that staff administered the medication 11 times in June 2025, 17 times in July 2025, and one time in August 2025, when the resident's SBP was greater than 120 mm/Hg. In an interview on August 7, 2025, at 12:15 p.m., the Administrator confirmed that medications were administered outside of the established parameters for Resident 4.…

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 facility policy review, facility documentation, and staff interview, it was determined that the facility failed to maintain clinical records that were complete and accurate for one of 26 sampled residents. (Resident 136) Review of facility policy entitled, Admissions, last reviewed January 20, 2025, revealed that the admissions process was intended to include obtaining all the information possible about the resident for the development of the comprehensive care plan, and to assist the resident in becoming comfortable in the facility.A review of facility documentation revealed that Resident 136 arrived at the facility on July 10, 2025, at 6:00 p.m., from the hospital for skilled and rehabilitation services, and was received and signed in by staff at 6:09 p.m. Documentation revealed that at 7:12 p.m., the kiosk recorded the resident left the facility with her husband. There was a lack of documentation in the clinical record to support that staff obtained all the information possible about the resident, including identifying information, during the admissions process.In an…

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 clinical record review, observation, and resident interview, it was determined that the facility failed to ensure that adaptive equipment to assist with eating was provided for two of 26 sampled residents. (Residents 52, 56) Findings include: Clinical record review revealed that Resident 52 had diagnoses that included dysphagia (difficulty swallowing), quadriplegia, muscle weakness, and a lack of coordination. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented. A review of the care plan revealed that the resident had difficulty manipulating utensils at meals with an intervention for staff to provide a rocker knife (an adaptive equipment to cut food) and built up utensils at meals. Observation on June 30, 2024, at 12:47 p.m.,revealed Resident 52 was in bed with her lunch and according to her meal ticket she was to receive a rocker knife and built up utensils. The resident did not have the adaptive equipment. In an interview at that time, Resident 52…

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 facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to maintain a medication error rate less than five percent on one of three nursing units. (West Unit) Findings include: A review of the facility policy entitled, Medication Administration, last reviewed January 30, 2024, revealed that staff were to administer medications as ordered by the physician. Medications were to be administered 60 minutes prior to or after the scheduled times unless otherwise specified by the physician. Clinical record review revealed that Resident 1 had diagnoses that included stroke, hypertension (HTN), and arthritic pain. A review of physician's orders dated January 5, 2024, and February 8, 2024, revealed that staff were to administer the following medications at 8:00 a.m. daily: tramadol (a pain medication) 50 mg, and metoprolol (a blood pressure medication) 25 mg. Observation of the medication pass on March 1, 2024, revealed that licensed practical nurse (LPN) 1 administered Resident 1's medications at 9:40 a.m. Clinical…

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 clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one of 24 sampled residents. (Resident 105) Findings include: Clinical record review revealed that section N of the MDS assessment dated [DATE], indicated that Resident 105 received an insulin injection for all days during the seven-day review period. Review of Resident 105's clinical record revealed that she was not prescribed and did not receive an insulin injection during the seven-day review period, as inaccurately identified on the MDS assessment. In an interview on August 4, 2023, at 11:32 p.m., the Director of Nursing confirmed that Resident 105's MDS assessment was inaccurate.

Based on clinical record review it was determined that the facility failed to ensure that a resident recieved trauma-informed care in accordance with professional standards of practice for one of 26 sampled residents. (Resident 55) Findings include: Clinical record review revealed that Resident 55 had diagnoses that included dementia, recurrent depressive disorder, and PTSD. A review of the psychologist's notes revealed the resident's PTSD was related to experiences related to active military service. Resident 55 was seen in regularly scheduled, semimonthly supportive care visits with psychological services from June 28, 2021, until November 17, 2022. On November 17, 2022, the psychologist recommended a follow up visit within one to two weeks. There was no documentation to support that the resident was seen again for this issue until July 6, 2023. Review of the resident's clinical record revealed that there was no documentation of assessments or trauma-specific interventions to meet the resident's needs for minimizing triggers or additional trauma between November 2022 and July…

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, staff interview, and a review of facility documentation, it was determined that the facility failed to maintain resident care equipment in safe operating condition for two of 26 sampled residents. (Residents 43, 75) Findings include: Clinical record review revealed that Resident 43 had diagnoses that included dementia and acute respiratory failure. Resident 43 had an order dated August 2, 2023, that staff provide oxygen via nasal cannula. On August 1, 2023, at 11:15a.m., Resident 43's oxygen concentrator had a heavy buildup of dust on the intake vent. The product manual recommended that the outside of the cabinet should be cleaned every week. In an interview on August 3, 2023, at 9:50 a.m., RN 1 confirmed the oxygen concentrator had a significant accumulation of dust on the vent. Clinical record review revealed that Resident 75 had diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure. Review of the most recent Minimum Data Set assessment, dated May 22, 2023, revealed the resident had no cognitive impairment and could…

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.