Westminster Suncoast

Inspectors wroteBased on record reviews, observations, and interviews the facility failed to ensure wound care was completed as ordered for two (#1 and #6) of three residents sampled for the treatment of non-pressure wounds, failed to ensure accurate and timely assessments were completed for two (#5 and #6) of three residents sampled for skin assessments.

Inspectors wroteBased on record reviews and interviews the facility failed to provide the services ordered by a physician for one (#1) of three residents sampled for treatment of a non-pressure wound. The facility falsified documentation showing wound care had been completed during that time and failed to recognize wound care had not been completed for 8 days during a weekly skin assessment.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure medications were stored securely and not accessible by unauthorized staff, visitors, and residents related to:1. medications left unattended on a medication cart on two (300/400) of three units; 2. medications left unattended in a resident's room for one resident (#7) who was not assessed to self-administer medications out of one resident sampled for self administration of medications.

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records with accurate documentation for one resident (#4) of three residents reviewed for incontinence care.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to ensuring staff members donned appropriate Personal Protective Equipment (PPE) to prevent the transmission of communicable conditions for two (#9 and #10) of five residents with physician orders for contact precautions. On 2/25/26 at 7:39 a.m. an observation showed Staff C, Certified Nursing Assistant CNA) dressed in wine-colored scrubs standing in front of Resident #9 (sitting in wheelchair) and speaking with the resident. The staff member left the room. Staff B, Licensed Practical Nurse (LPN) confirmed a Contact Precautions sign was posted on the resident's door and no Personal Protective Equipment (PPE) was available at the doorway. Review of the Contact Precaution sign posted on Resident #9's door Instructed, STOP CONTACT PRECAUTIONS EVERYONE MUST: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the rights of one (#6) of one resident related to the physical abuse from a staff member.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an alleged violation involving abuse immediately or no later than 2 hours for one (#6) out of eight sampled allegations of abuse. .

Inspectors wroteBased on interviews and record review, the facility failed to ensure an accurate care plan was in place related to Advanced Directives for one resident (#101) out of 40 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure pressure relieving boots were applied to prevent the worsening of a pressure wound for one resident (#101) out of one resident sampled for pressure wounds.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure identification and monitoring of a BIPAP (Biphasic positive airway pressure) machine was in place for one resident (#6) out of one resident sampled.

Inspectors wroteBased on record review and interviews, the facility failed to ensure ongoing assessment and monitoring of the dialysis fistula (dialysis access port) before and after dialysis treatments for one resident (#37) out of three residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one resident (#72)with Post Traumatic Stress Disorder (PTSD) was assessed to identify triggers which may re-traumatize the resident out of 40 residents sampled. Findings Included: On 04/25/2024 at 2:00 and 3:00 p.m., Resident #72 was observed sitting with a group of residents attending an activity. Review of the admission Record for Resident #72 showed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Type 2 Diabetes Mellitus without complications, and post-traumatic stress disorder, unspecified. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a paid caregiver for one resident (#205) out of 40 sampled residents had specific competencies and skill sets necessary to care for the resident's care needs.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and eighteen errors were identified for three residents (#130, #79, #131) observed. These errors constituted a 66.67% medication error rate.

Inspectors wroteBased on observation, record review, and interview, the facility failed to treat residents with respect and dignity related to one (Resident #230) of six residents with an indwelling catheter who did not have a privacy cover on the urine drainage bag, on two (02/13/2022 and 02/15/2022) of four survey days.

Inspectors wroteBased on record review, interviews, and policy review, the facility did not ensure the advance directive wishes were implemented for one resident (#35) of eighty-three residents reviewed for advance directives.

Inspectors wroteBased observation, interview, and record review, the facility failed to implement the care plan for one (Resident #34) of two residents sampled for vision and hearing. The facility staff failed to offer Resident #34 their eyeglasses on three of three observed days. The failure of the staff to offer Resident #34 their eyeglasses per the care plan, resulted in a failure to identify Resident #34's eyeglasses were missing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain and verify laboratory results for a physician ordered urinalysis (U/A) for one (Resident #6) of two residents sampled for urinary tract infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that 1) temperatures of food held for meal service were taken and recorded in facility temperature logs before serving to residents for all resident units and 2) that clean dishware used for resident food service throughout the facility was stored under sanitary conditions in the kitchen.

Inspectors wroteBased on observations, record review, interviews, and policy review the facility did not ensure the medication error rate was below 5% regarding two residents (#55 and #175) of six sampled residents observed during medication administration. This resulted in four errors from 25 opportunities and a medication error rate of 16%.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure a clean and sanitary environment for one resident room (216) on one of four units surveyed.