Buckner Westminster Place

In the surveyor’s words

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

• Immediate jeopardy, patternF755May 9, 2024

  Based 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. […]

• Immediate jeopardy, patternF760May 9, 2024

  Based 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. […]

• Actual harm, patternF580Mar 11, 2025

  Based 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. […]

• Actual harm, patternF684Mar 11, 2025

  Based 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 9/13/2024. The facility failed to clarify hospital discharge orders for surgical incision site care upon admission on 9/13/2024 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). […]

• No harm, potential for more than minimal, patternF812Jul 15, 2026

  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. 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.The findings were:During an initial tour of the kitchen on 7/13/26 at 8:30 a.m. it was observed that staff were not thawing sausage and ham properly in the kitchen sink. […]