Inspection Reports for
Buckingham Pavilion Nursing and Rehabilitation

F0550 (295.6050 Resident Rights) - The facility failed to maintain privacy for one resident during bedside care when the privacy curtain was not used and the door was left open exposing the resident.

F0558 (295.6058 Reasonable Accommodations) - The facility failed to ensure the call light was within reach for one resident, risking delayed assistance and falls.

F0583 (295.6083 Confidentiality) - The facility failed to maintain confidentiality of medication administration records for three residents by leaving computer screens unlocked and visible.

F0644 (295.6044 PASRR) - The facility failed to refer four residents with newly evident or possible serious mental disorders for updated Preadmission Screening and Resident Review (PASRR).

F0677 (295.6077 Activities of Daily Living) - The facility failed to perform routine wellbeing checks every two hours for one resident, resulting in the resident not being changed or repositioned timely.

F0693 (295.6093 Feeding Tubes) - The facility failed to label enteral nutrition bottles with resident name, date, start time, and rate for one resident receiving tube feeding.

F0790 (295.6090 Dental Services) - The facility failed to provide dental services for one resident who had difficulty chewing due to lack of upper teeth and no dentures.

F0842 (295.6084 Medical Records) - The facility failed to grant timely and complete access to residents' electronic health records to the survey team, potentially affecting all residents.

F0883 (295.6083 Vaccinations) - The facility failed to provide influenza and pneumococcal vaccinations and failed to document resident education or consent for three residents.

F0550 (295.6000 Resident Rights) - The facility failed to provide care in a manner to promote dignity for two residents, including improper feeding assistance and undignified transport in a shower chair.

F0684 (295.6800 Medication Administration) - The facility failed to clarify a physician's order for Olanzapine dosage for one resident, resulting in confusion about the correct medication dose.

F0692 (295.6900 Nutrition and Hydration) - The facility failed to complete nutritional assessments for a resident with significant weight loss and did not adjust interventions timely.

F0695 (295.6950 Respiratory Care) - The facility failed to ensure respiratory care equipment was stored properly to prevent contamination for three residents.

F0761 (295.7600 Drug Storage) - The facility failed to label open insulin vials and pens with open and discontinue dates for two residents.

F0803 (295.8000 Food Service) - The facility failed to follow standardized recipes during pureed food preparation, risking inadequate nutrition for six residents.

F0805 (295.8050 Food Service) - The facility failed to follow physician orders for a resident's pureed diet and did not update the care plan accordingly.

F0812 (295.8120 Food Safety and Sanitation) - The facility failed to use utensils or gloves when handling resident food, failed to properly store food items, failed to perform hand hygiene between handling dirty and clean kitchenware, and failed to air dry kitchen equipment before use.

F0550 (Resident Rights) - The facility failed to ensure that one resident's urinary catheter drainage bag was covered with a privacy cover, affecting one resident in a sample of 45.

F0558 (Reasonably accommodate the needs and preferences of each resident) - The facility failed to ensure that a call light was within reach for one resident from a sample of 45.

F0658 (Ensure services provided by the nursing facility meet professional standards of quality) - The facility failed to check placement of the gastrostomy tube before connecting the tube feeding after ADL care for one resident receiving tube feeding.

F0686 (Provide appropriate pressure ulcer care and prevent new ulcers from developing) - The facility failed to ensure the low air loss mattress setting was based on resident's weight and/or mode for one resident reviewed for pressure injury prevention.

F0695 (Provide safe and appropriate respiratory care for a resident when needed) - The facility failed to ensure that oxygen tubing and humidifier bottles were changed and dated for five residents reviewed for respiratory care.

F0755 (Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist) - The facility failed to maintain shift change accountability records for controlled substances for residents' controlled medications, affecting all 64 residents on the second and third floors.

F0761 (Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs) - The facility failed to ensure that residents' expired eye drops were discarded and failed to label opened multidose eye drops with open dates, affecting five residents reviewed for medication storage.

F0812 (Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards) - The facility failed to ensure expired food was discarded on or before the expiration date in the walk-in cooler, potentially affecting 86 residents receiving an oral diet.

F0880 (Provide and implement an infection prevention and control program) - The facility failed to ensure that a staff member used personal protective equipment and performed hand hygiene before entering and exiting a contact isolation room, affecting one resident in a sample of 45.

F0919 (Make sure that a working call system is available in each resident's bathroom and bathing area) - The facility failed to have an operational call light for one resident reviewed for accommodation of needs.