Life Care Center of Westminster

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for one (#1) of three residents out of eight sample residents. Resident #1, who had a history of falls and previous fractures that included a right humerus (long bone in the upper arm) fracture, was admitted to the facility on [DATE]. On 3/1/26 at 3:30 a.m. Resident #1, who required maximum assistance from staff with transfers, fell out of bed. Registered nurse (RN) #1 heard a loud sound and found Resident #1 on the floor next to her bed lying on her left side in a somewhat fetal position partially on the fall mat. The bed was raised in a high position. RN #1's initial assessment revealed Resident #1's blood pressure was 184/95 millimeters of mercury (mmHg) and she had no injuries. (A normal blood pressure is generally below 120/80 mmHg). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#41) of five residents reviewed for pressure injuries out of 33 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing. Resident #41 was admitted on [DATE] for long term care. At the time of his admission, the resident was identified as being at risk for developing pressure injuries and he did not have any pressure injuries upon admission. On 12/2/24 the facility documented Resident #41 had a new wound with an open area on his left inner heel measuring 3.0 centimeters (cm) by 0.9 cm. The facility failed to implement preventative measures to protect the resident's heels after the development of the left heel wound on 12/2/24. On 12/4/24 a nurse progress note indicated Resident #41 had an unstageable pressure wound to his left heel. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure prompt action was taken to resolve grievances from a group. Specifically, the facility failed to resolve residents' concerns regarding not enough floor staff to provide care such as showers, call light wait times and no hot water for showers.

Inspectors wroteBased on record review and interviews, the facility failed to ensure three (#61, #15 and #28) of five residents reviewed for psychotropic medications out of 33 sample residents were as free from unnecessary medication as possible. Specifically, the facility failed to: -Ensure Resident #15 and Resident #61 had appropriate mood and behavior monitoring in place for their psychotropic medication in order to justify and determine effectiveness of the medications; -Ensure Resident #15 had the proper diagnoses for the use of an antipsychotic (a class of drugs used to treat psychosis, particularly in conditions like schizophrenia and bipolar disorder) medication; -Provide a physician's clinical rationale to justify the use of two antidepressant medications for Resident #28; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility's medication error rate was 13%, which was four errors out of 29 opportunities for error.

Inspectors wroteBased on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident abuse prevention for five of five staff members reviewed. Specifically, the facility failed to ensure certified nurse aide (CNA) #1, CNA #2, CNA #3, registered nurse (RN) #1 and licensed practical nurse (LPN) #1 received annual abuse identification, prevention and reporting training in the past 12 calendar months.

Inspectors wroteBased on record review and interviews, the facility failed to honor resident choices for two (#53 and #26) of four residents reviewed out of 33 sample residents. Specifically, the facility failed to ensure Resident #53 and Resident #26's recevied showers consistently according to the resident's choices and plan of care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#28) of five residents reviewed for grievances out of 33 sample residents was provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to promptly resolve Resident #28's grievance regarding care provided by certified nurse aide (CNA) #3.

Inspectors wroteBased on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one (#28) of five residents reviewed for medication management out of 33 sample residents. Specifically, the facility failed to ensure Resident #28 was administered medications per physician's orders in April 2025.

Inspectors wroteBased on record review and interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner for one (#15) of five residents out of 33 sample residents. Specifically, the facility failed to ensure the physician documented that he or she reviewed the pharmacist's identified monthly drug regimen review irregularities and documented the actions taken or not taken to address the irregularities for Resident #15.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance for two (#41 and #35) of five residents out of 33 sample residents. Specifically, the facility failed to ensure a physician's rationale for the use of long-term antibiotics was provided for Resident #41 and Resident #35.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents had the right to a dignified existence for two (#1 and #3) of three residents out of three sample residents Specifically, the facility failed to ensure residents' call lights were answered in a timely manner.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of three residents out of three sample residents was kept free from neglect. Resident #1, who had a known history of falls and was dependent on staff for transfers, had a documented plan of care which required the assistance of two staff members for transfers with a mechanical lift. The resident was unable to perform a stand and pivot transfer related to her diagnosis of cerebral palsy (affects the body movement, muscle control, reflexes, posture and balance). On 1/26/24 a facility certified nurse aide (CNA) requested assistance from an agency CNA to help transfer Resident #1 from a shower chair to the resident's wheelchair with a mechanical lift. [...]

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to address and/or act promptly upon the grievances and recommendations of resident council concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to ongoing concerns brought up during the resident council meetings. The failure resulted in residents' concerns unaddressed and feelings of not being heard for a pattern of facility residents.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of five medication carts and three of three medication storage refrigerators. Specifically the facility failed to: -Remove expired medications from medication carts and medication storage refrigerators to prevent the use of expired medications; -Date medications and liquid protein supplements when opened; and, -Ensure the medication storage refrigerator temperatures were monitored and documented consistently.

Inspectors wroteBased on interviews and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced their dignity and respect for one (#33) of six residents reviewed for dignity out of 29 sample residents. Specifically, the facility failed to ensure Resident #33 ' s care needs were discussed with the resident in an appropriate and dignified manner.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances for one (#33) of six residents reviewed for grievances out of 29 sample residents. Specifically, the facility failed to ensure Resident #33's concerns regarding certified nurse aide (CNA) #6 consistently being unavailable to assist with the resident's transfers was resolved timely by the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a discharge summary was in place for one (#75) of three residents reviewed for discharge out of 29 sample residents. Specifically, the facility failed to ensure discharge summaries included a recapitulation of the resident's stay and/or a final summary of the resident's status was completed for Resident #75.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (#6) of four residents reviewed for restorative services for 29 sample residents. Specifically, the facility failed to ensure Resident #6's right hand splint was applied for contracture management per physician's orders.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured residents received adequate supervision and assistance to prevent accidents for two (#55 and #63) of three residents out of 29 sample residents. Specifically, the facility failed to ensure: -Appropriate supervision was in place to prevent potential safety hazards for Resident #55; and, -A thorough fall investigation was conducted with corresponding fall interventions with timely implementation to prevent future and similar falls for Resident #63.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice for one resident (#55) of four residents reviewed for oxygen use out of 29 sample residents. Specifically, the facility failed to ensure: -Resident #55 had oxygen in place as ordered and with appropriate monitoring; -Resident #55 was placed on correct order setting for oxygen via nasal cannula; -Certified nurse aides (CNAs) did not administer medication, specifically oxygen; -Staff care directives such as the care plan, where accurate; and, -Accurate recording and/or completion of the oxygen administration on the medication administration record (MAR).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (#163) of one resident reviewed out of 32 sample residents. Resident #163 admitted to the facility on [DATE] with diagnoses of open wound to right and left foot, infections of skin and subcutaneous tissue (deepest layer of the skin mostly made of fat and connective tissue), osteomyelitis (infection in bone), and diabetes mellitus. The 4/21/22 pain assessment revealed the resident had pain to her right and left heel. Her most recent pain level was a 7 out of 10 (with 10 being the worst pain on a scale), and her acceptable pain level was a 3 out of 10. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was stored under safe and sanitary conditions in three of three facility refrigerators. Specifically, the facility failed to ensure foods stored unlabeled and undated in the nourishment room refrigerators on each of the three units designated for the residents.

Inspectors wroteBased on observations and interviews, the facility failed to follow proper testing procedures and infection control measures to prevent potential cross-contamination and spread of SARS-CoV-2 COVID-19, during testing procedures on staff and residents. Specifically, the facility failed to: -Ensure COVID-19 rapid (antigen) testing of staff was conducted in a location, which provided other individuals (resident, staff and visitors) protection from aerosolized particles that may be discharged during the testing procedure; -Ensure properly disinfection of the testing area and testing supplies between staff self-tests; -Ensure the entire testing and all items in the testing area (within six feet of the testing) were properly disinfected every hour during the testing period; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to: -To provide resolutions to food concerns voiced by residents in the food committee and resident council; and, -To follow-up with Resident #19 had a grievance about her roommate having the television on all night.

Inspectors wroteBased on record review and interview, the facility failed to ensure two (#58 and #8) of three residents out of 32 sample residents did not experience a significant medication error. Specifically, the facility failed to ensure -For Resident #58, ensure the prescribed physician's order for Lorezpam was transcribed correctly into the medical record as an as needed (PRN) order and not a routinely scheduled order as not to over sedate or lead to other side effects; -For Resident #58 recognize signs and symptoms of over sedation due to the medication transcription error of Lorazepam; and, -For Resident #8 follow physician's orders to hold the resident's insulin when the resident blood glucose levels fall below a physician-determined perimeter. I. Professional reference According to [NAME] Nursing Drug Handbook 2020, Kizior, R. J. and [NAME], K.J., St. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including unvaccinated staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to: -Monitor and maintain documentation of COVID-19 vaccination history and status for each facility hired and contracted staff member (licensed practitioners, students, trainees, and individuals who provide care, treatment or other services for the facility and or its residents under contract or by other arrangement) working with residents throughout the facility to ensure proper advanced personal protective equipment (PPE) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19; [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible by accommodating the needs and preferences of one (#18) of four out of 32 sample residents. Specifically, the facility failed to ensure Resident #18's call light was within reach when in their room.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that one (#39) out of two residents reviewed for oxygen out of 32 sample residents, received necessary respiratory care and services. Specifically, the facility failed to administer oxygen according to physician orders for Resident #39.