Buckner Westminster Place

Based 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. Findings include: Record review of an undated dietary staff list revealed [NAME] A (hired 4/22/25), and Waitstaff B (hired 4/22/25) did not have a Food Handler's Certificate. [NAME] C's (hired 7/21/11) Food Handler's Certificate expired on 3/15/25. During an interview on 6/02/25 at 2:32 PM, the ADM said he…

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 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 . These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include: 1. Record review of…

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 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. Findings included: Record review of personnel records for the Director of Culinary Services indicated a hire date of 01/13/25. The file did not indicate training on the topics of HIV, restraint reduction, fall prevention, resident rights, behavioral health, or infection prevention and control for the Director of Culinary Services. During an interview on 06/04/25 at 11:41 AM, the HR Director said the Director of Culinary Services was responsible for taking care of his…

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 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. Findings included: Record review of personnel records for the Director of Culinary Services indicated a hire date of 01/13/25. The file did not indicate any abuse training for the Director of Culinary Services. During an interview on 06/04/25 at 11:41 AM, the HR Director said the Director of Culinary Services was responsible for taking care of his trainings that were required. She said the managers got emails about their trainings and they were responsible for taking their own trainings. She said he had not completed any of his required trainings. During an interview on…

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 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. Findings included: Review of Resident #1's face sheet dated 05/15/2024 indicated Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid). Review of Resident #1's quarterly MDS assessment…

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, 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. The findings were: During an observation on 5/13/2024 at 9:25 AM, it was observed a utility cart with 3 cans of paint, 1 can of primer, 4 bottles of goo gone and WD 40 located in dry food storage area near juice box storage. During an observation on 5/14/2024 at 8:10 AM, it was observed the utility cart remained in dry storage room with 3 cans of paint, 1 can of primer, 4 bottles of goo be gone and WD 40 located in dry food storage area near juice box storage. During 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 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.Review of Resident #1's face sheet dated 05/15/2024 indicated Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid) and parkinsonism (a disorder of the central…

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 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. Findings included: During an observation on 5/15/2024 at 10:46 a.m., CNA K opened the laundry door at the [NAME] House and located in front of the washer was soiled clothing, towels, wash clothes sitting in a shower chair and a white laundry basket seated on the floor directly in front of the shower chair. Located in the washer was 1 load of clothing sitting in the washer. CNA K said big blankets go in the yellow bins and was transferred to the bigger laundry room located in the main building. CNA K said soiled…

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 interviews and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 1 of 5 residents (Resident #7) reviewed for right to be informed about consents. The facility failed to ensure Resident #7 had signed psychotropic consent for Lorazepam (antianxiety). This failure could place residents at risk of receiving medications without their prior knowledge or informed consent, or that of their responsible party. The findings included: Record review of Resident #7's face sheet, dated 03/23/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with the diagnoses which included Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), atrial fibrillation (extremely…

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 interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 2 of 5 residents (Residents #7 and #12) reviewed for care plan timing and revisions. 1. The facility failed to ensure Resident #7's care plan was updated to include psychotic medication of lorazepam. 2. The facility failed to ensure Resident #12's care plans was updated to reflect a problem for diuretic and interventions. These deficient practices could place residents at risk of not receiving appropriate care to meet their current needs. Findings included: 1. Record review of Resident #7's face sheet, dated 03/23/23, indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and…

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 observation, interview, and record review, the facility failed to establish and 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 2 of 10 residents (Residents #8 and #4) reviewed for infection control practices. 1. CNA A failed to change her gloves and sanitize her hands after performing peri care to Resident #8. 2. LVN C failed to change gloves and sanitize his hands after cleaning Resident #4's wound and before applying treatment as ordered during wound care. These failures could place residents at risk for infections. Findings include: 1. A record review of Resident #8's, undated, face sheet indicated she was83-years-old who was admitted to the facility on [DATE], with diagnoses which included: fracture of left femur (broken hip), pain in left hip, Alzheimer's Disease (progressive mental deterioration), and acute cystitis (inflammation…

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.