Westminster Towers

Inspectors wroteBased on interview, and record review, the facility failed to follow physician orders and ensure the comprehensive care plan was implemented for 1 of 5 residents reviewed for unnecessary medications and medication regimen, of a total sample of 34 residents, (#43).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' self-administration of medication for 2 of 2 residents reviewed for self-administration of medications, of a total sample of 33 residents, (#57, and #83). 1. Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including drug-induced secondary Parkinsonism, bipolar disorder, hypertensive heart disease, and dementia. A review of the Minimum Data Set (MDS) quarterly assessment with an assessment reference date of 12/23/24, revealed resident #57 had a Brief Interview for Mental Status (BIMS) score of 13/15, indicating he was cognitively intact. On 3/10/25 at 1:58 PM, resident #57 was sitting on the right side of his bed. His nightstand was observed with a one-ounce Neosporin ointment. He stated he used it on the small rash on his right thigh. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a written summary of the baseline care plan was provided to 1 of 2 residents reviewed for care plans, (#390); and failed to provide a written summary of the baseline care plan within the required time frame for 1 of 2 residents reviewed for care plans, (#546), of a total sample of 34 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers per resident preference and as scheduled for 1 of 2 resident reviewed for Activities of Daily Living (ADLs), of a total sample of 34 residents, (#75).

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an outside eye specialist appointment for 1 of 1 residents reviewed for care coordination, of a total sample of 34 residents, (#45).

Inspectors wroteBased on interview, and record review, the facility failed to ensure documentation was accurate and complete for 1 of 1 resident reviewed for accidents, of a total sample of 34 residents, (#55).

Inspectors wroteBased on interview, and record review, licensed nurses failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of code status in an emergency for 1 of 13 residents reviewed for advance directives, (#1). On [DATE] at approximately 7:00 PM, resident #1 was observed unresponsive in her bed. Registered Nurse (RN) A took her vitals and notified RN C resident #1 had passed away. RN A failed to verify resident #1's code status and failed to provide CPR per her wishes. Emergency Medical Services was never called. The facility failed to honor the resident's wish to be resuscitated and the physician order for Full Code status. The facility's failure to ensure staff followed procedures related to honoring an advance directive to provide lifesaving measures including CPR for a resident on hospice care contributed to resident #1's death. [...]

Inspectors wroteBased on interview and record review, the facility failed to report timely an alleged violation of neglect for 1 of 1 resident reviewed for neglect, of a total sample of 3 residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement for 1 of 1 resident reviewed for actual elopement, of a total sample of 3 residents reviewed for elopement, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for medications at bedside for 1 of 3 residents reviewed for pressure ulcer care, of a total sample of 8 residents, (#2).

Inspectors wroteBased on interview, and record review, the facility failed to ensure wound care for pressure ulcers was completed per physician's orders for 2 of 3 residents reviewed for pressure ulcers, of a total sample of 8 residents, (#1, and #2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Peripheral Inserted Central Catheter (PICC) line dressing was changed as per physician's order, and professional standard of practice to prevent the potential for infection for 1 of 8 residents, (#2). A PICC is a thin, flexible tube that is inserted into a vein in the upper arm . It is used to give intravenous fluids, . chemotherapy, and other drugs. (retrieved on 5/31/24 from www.cancer.gov).

Inspectors wroteBased on interview, and record review, the facility failed to ensure medical records were accurate regarding a Peripheral Inserted Central Catheter (PICC) line dressing for 1 of 1 residents reviewed for PICC lines, of a total sample of 8 residents, (#2). A PICC is a thin, flexible tube that is inserted into a vein in the upper arm . It is used to give intravenous fluids, . chemotherapy, and other drugs. (retrieved on 5/31/24 from www.cancer.gov).

Inspectors wroteBased on interview, and record review, the facility failed to honor resident preferences for showers for 1 of 3 residents reviewed for choices, of a total sample of 34 residents, (#101).

Inspectors wroteBased on interview, and record review, the facility failed to ensure that an accurate comprehensive, Minimum Data Set assessment was completed for 1 of 34 sampled residents who were admitted to the facility, (#36).

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for 2 of 5 residents reviewed for PASRR that were later identified with Intellectual Disability (ID) or Serious Mental Illness (SMI) out of a total sample of 34 residents, (#76, #48).

Inspectors wroteBased on interview and record review the facility failed to ensure blood glucose monitoring was conducted as per the physician's orders for 1 of 1 resident of a total sample of 34 residents, (#358).

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment regarding hospice services for 1 of 3 residents reviewed for hospice services, of a total sample of 35 residents, (#17).

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for hospice and ensure care plans reflected the goals of hospice services for 1 of 3 residents reviewed for hospice services, (#17); and failed to develop a person-centered care plan for intravenous antibiotic therapy for 1 of 1 resident reviewed for antibiotic therapy, (#34), of a total sample of 35 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nail care for 1 of 4 dependent residents reviewed for activities of daily living (ADL) care, of a total sample of 35 residents, (#59).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure wheelchair anti-tippers were positioned correctly to prevent accidents for 1 of 5 residents reviewed for falls and accident hazards, of a total sample of 35 residents, (#44).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dressing changes for a midline intravenous (IV) catheter according to current professional standards of practice, for 1 of 1 resident reviewed for IV catheters of a total sample of 35 residents, (#34).