Buchanan Place

In the surveyor’s words

From the most serious findings on record at Buchanan Place, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 10, 2024

  Based 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 6/18/2024, 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. […]

• No harm, potential for more than minimal, widespreadF686Sep 9, 2022

  Based on the facility policy, medical record review, observation, and interview, the facility failed to follow physician orders for pressure ulcer treatments and failed to provide weekly pressure ulcer measurements for 3 residents (#2, #9, and #10) of 3 residents reviewed for pressure ulcers. The findings included: Review of the facility policy Skin Care Guideline, dated 7/2018, showed, .to provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity .document evaluation of wound .including .location and staging .size (length x [times] width x depth) .exudate .pain .wound bed .reassess, re-evaluate and revise interventions when progress is not noted within 14 days .pressure… […]

• No harm, potential for more than minimal, widespreadF812Jun 29, 2022

  Based 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. The findings include: Review of the facility policy Facility Nourishment Refrigerators/and Nourishment Rooms, undated, showed .employees are to use the designated refrigerator in the employee break room. […]

• No harm, potential for more than minimal, patternF756May 10, 2024

  Based 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. The findings include: Review of the facility's, Medication Disposal and Returns Policy, effective 6/21/2017, showed .Nursing staff is responsible for removing all discontinued medications from the cart and/or storage areas. […]

• No harm, potential for more than minimal, isolatedF644Jun 24, 2026

  Based 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.The findings include: Review of the facility's PASRR (Preadmission Screening and Resident Review) Policy, undated, revealed .The facility shall ensure .Timely identification of residents requiring Resident Review due to significant changes in status .Level I Screening .Initial screening performed prior to admission or when a significant change in status occurs . Review of a Level 1 PASRR dated 6/30/2025 (prior to admission), revealed Resident #4 had diagnoses of Anxiety Disorder and Mild or Situational Depression. […]