Westminster Canterbury Blue Ri

Inspectors wroteBased on observation, resident, staff, and family interviews, the facility staff failed to ensure safe transfer from bed to wheelchair for one (1) of 24 residents (Resident #7) in the survey sample, which resulted in harm, sustaining a right hip fracture.

Inspectors wroteBased on observation, resident and staff interviews, and a review of clinical records, the facility staff failed to accurately assess and classify an open wound for 1 of 24 residents (Resident #30) in the survey sample.

Inspectors wroteBased on staff interviews and review of facility documents, the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility to ensure effective systems were in place to assure the quality of life for the residents in the area of foot care and treatment/services to prevent/heal pressure ulcers.

Inspectors wroteBased on staff interviews and review of facility documents, the facility staff failed to adequately identify, keep systems functioning properly, and implement necessary action plans to assure the quality of life for the residents using the Quality Assurance and Performance Improvement (QAPI) committee to identify deficiencies if the area of foot care and treatment/services to prevent/heal pressure ulcers.

Inspectors wroteBased on observations, staff interviews, and a review of the clinical record, the facility staff failed to treat 1 of 24 residents (Resident 20) in the survey sample with respect and dignity.

Inspectors wroteBased on observations and staff interviews, the facility staff failed to ensure that resident care equipment was kept clean for 1 of 24 residents (Resident 31) in the survey sample.

Inspectors wroteBased on observations, staff interviews, and a review of the clinical record, the facility staff failed to ensure that 1 of 24 residents (Resident 49) in the survey sample was free from a physical restraint.

Inspectors wroteBased on resident interview, staff interview, facility document review, it was determined that facility staff failed to report an allegation of verbal abuse in a timely manner to the appropriate state agencies for 1 of 24 residents (Resident #11) in the survey sample. Resident #11 was originally admitted to the facility 6/10/24 after an acute care hospital stay and re-admitted on [DATE] from an acute care facility. The current diagnoses included; Foot Drop, Peripheral Vascular Disease. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/02/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #11 cognitive abilities for daily decision making were intact. [...]

Inspectors wroteBased on observation, staff interviews and clinical record review, the facility staff failed to ensure 1 resident (Resident #11), in the survey sample of 24 Residents who were unable to carry out activities of daily living receive the necessary services to maintain podiatry services.

Inspectors wroteBased on observations, staff interviews, and a review of the clinical record, the facility staff failed to provide necessary incontinence care for 1 of 24 residents (Resident 20) in the survey sample.

Inspectors wroteBased on observations, staff interviews, and a review of the clinical record, the facility staff failed to serve 1 of 24 residents (Resident 20) in the survey sample the food necessary to support nutritional needs.

Inspectors wroteBased on observations during the medication administration task, staff interviews, and a review of the clinical record, the facility staff failed to ensure that its medication error rate was not 5% or greater. The medication error rate was identified as 11.54%.

Inspectors wroteBased on observation, resident interview and staff interview, the facility's staff failed to provide a homelike environment for one resident (Resident #4) in the survey sample of 24 residents. Resident #4 was originally admitted to the facility 02/06/23 after an acute care hospital and readmitted on [DATE]. The current diagnoses included; Major depressive disorder and Muscle weakness, generalized. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/02/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #4 cognitive abilities for daily decision making were intact. On 4/14/26 at approximately 11:30 am., during the initial tour of room [ROOM NUMBER]-1 Resident #4 was observed sitting in his recliner. [...]

Inspectors wroteBased on observation, facility document review and staff interview, the facility staff failed to ensure proper function of one of two walk-in freezers serving the main kitchen.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of fifteen residents in the survey sample (Resident #32).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for one of fifteen residents in the survey sample (Resident #25).

Inspectors wroteBased on staff interview, clinical record review, and facility policy review, the facility staff failed to ensure professional standards of nursing were followed for one of 15 residents, Resident #4.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to follow physician orders for one of 15 residents, Resident #4.

Inspectors wroteBased on observations, clinical record review, and staff interview, the facility staff failed for one of 15 residents in the survey sample (Resident # 2) to provide pressure ulcer treatment consistent with professional standards of practice. Staff failed to properly clean work surfaces, as well as employ handwashing during a dressing change.

Inspectors wroteBased on observation, facility document review, and staff interview, the facility staff failed to ensure expired insulin was not available for use on one of two inspected medication carts (second-floor cart).

Inspectors wroteBased on observations, clinical record review, staff interview, and review of facility policy and procedure, the facility staff failed for one of 15 residents in the survey sample (Resident # 2) to follow infection control practices during a pressure ulcer dressing change. The staff member performing the dressing change failed to establish a clean surface for supplies, and failed to perform hand hygiene during glove changes.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to review and revise a comprehensive care plan for 1 of 10 in the survey sample, Resident #14. Resident #14's care plan was not reviewed and revised for the discontinuation of psychotropic medication.