Westminster Village

Inspectors wroteBased on observation and interview, the facility failed to post notice of the availability of state agency survey results. This failure has the potential to affect all 43 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to post the daily staffing data in a prominent location that is accessible to residents, staff, and visitors. This failure has the potential to affect all 43 residents in the facility.

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation and interview, the facility failed to maintain the hot water supply in resident bathrooms and showers in safe operating temperatures. This failure affects seven residents (R3, R11, R13, R36, R47, R48, and R52) out of eleven reviewed for water temperatures on the sample list of 25. B. Based on observation, interview, and record review the facility failed to provide adequate supervision for one of three residents (R8) reviewed for wandering on the sample list of 25.

Inspectors wroteBased on interview and record review the facility failed to protect resident's rights to be free from resident to resident physical abuse. This failure affects two of three residents (R8, R9) reviewed for abuse on the sample list of 25. Findings Include: The facility's Abuse Prevention, Reporting, and Investigation Policy revised May 2026 documents the facility prohibits and is committed to preventing abuse involving any resident. Abuse is the willful infliction of injury. Physical abuse includes hitting, slapping, rough handling or unnecessary force. It is any intentional physical action that causes or could cause harm. R8's Care Plan dated 5/7/26 documents R8 is diagnosed with Alzheimer's Disease. R8 forgets safety concerns and will walk in his room and hallway without assistance. R8 has a history of wandering. [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of physical abuse to the State Survey Agency. This failure affects two of three residents (R8, R9) reviewed for abuse on the sample list of 25. Findings Include: The facility's Abuse Prevention, Reporting, and Investigation Policy revised May 2026 documents the facility prohibits and is committed to preventing abuse involving any resident. Abuse is the willful infliction of injury. Physical abuse includes hitting, slapping, rough handling or unnecessary force. It is any intentional physical action that causes or could cause harm. Allegations involving abuse must be reported to the state surveying agency and other required authorities no later than four hours after the allegation is made known. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure physician-ordered daily weights were obtained and documented for two (R1 and R4) of the four residents reviewed for edema in a total sample of 10 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment for a resident on enhanced barrier precautions for 1 of 3 residents (R4) reviewed for infection control in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure the admissions contract did not waive potential facility liability for losses of residents' personal property. This failure affects all 42 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent further potential abuse by failing to remove an alleged perpetrator (V7 Certified Nursing Assistant (CNA)) from resident care. This failure affects eight (R140, R4, R35, R22, R142, R141, R18, R31) of eight residents reviewed for abuse in the sample list of 32.

Inspectors wroteBased on interview and record review the facility failed to document a root cause or obtain witness statements for fall investigations for four residents (R8,R17,R25,R35) of four residents reviewed for falls in a sample list of 32 residents.

Inspectors wrote4. R8's current physician's orders printed 6/10/25 include a physician's orders for an indwelling urinary catheter. R8's hospital admission paperwork dated 4/29/25 to 4/30/25 documents R8 was diagnosed and treated for a Urinary Tract Infection. On 6/8/25 at 2:00PM R8 was observed to have a urinary catheter attached to a drainage bag hanging on the side of his bed. There was no sign on the door to indicate Enhanced Barrier Precautions (EBP) were in place and no bin of Personal Protective Equipment observed outside R8's door. On 6/9/25 at 3:07 PM V2, Director of Nursing verified that since R8 has an indwelling urinary catheter he should be on EBP and further verified R8 is not on EBP. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to respect the dignity of one resident of 12 residents (R5) reviewed for dignity in a sample list of 32. Findings Include: R5's current diagnoses list printed 6/10/25 includes the following diagnoses: Parkinson's Disease, Cognitive Communication Deficit, Difficulty in Walking, Muscle Weakness, Lack of Coordination, Dysphagia, Psychotic Disorder, Anxiety, and Major Depression. On 6/8/25 at 8:45AM R14, (R5's roommate/spouse) stated The staff always leave my wife in the dining room until last. She is in the dining room now with her breakfast all over her wheelchair. Sometimes they really rush (R5). She has Parkinson's and it upsets me to see this. (R5) gets anxious and will fight them (the staff). R5 was observed to be in the dining room with only one other resident. [...]

Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from misappropriation of property for one of one resident (R14) reviewed for misappropriation in a sample of 32 residents.

Inspectors wroteBased on interview and record review the facility failed to complete a baseline assessment or identify and track targeted behaviors, prior to restarting an antipsychotic medication for one resident (R14) of five residents reviewed for unnecessary medication in a sample list of 32 residents. Finding Include: R14's current physician's orders include an order dated 4/16/25 for Olanzapine (antipsychotic) Oral Tablet 2.5 MG (milligrams), Give 1 tablet by mouth one time a day. R14's Medication Administration Record (MAR) documents this medication had previously been discontinued on 3/19/25. There is no documentation to indicate a baseline assessment was completed when restarting this antipsychotic medication. There is no documentation of identification or tracking of target behaviors for the justification of this medication. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a care plan was accurate and updated to reflect current fall interventions for one (R25) of four residents reviewed for falls in the sample list of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate hospice care to address positioning needs for one (R25) of one resident reviewed for positioning in the sample list of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two (R5, R21) of two residents reviewed for nutrition in the sample list of 31. These failures resulted in R5 experiencing a severe weight loss of 16.65% (percent) in six months and R21 experiencing a 15.6% severe weight loss in two months.

Inspectors wroteBased on observation, interview and record review the facility failed to label opened prepared foods with the date and time in the refrigerator. This failure has the potential to affect all 90 residents who reside in the facility. Findings Include: The facility's midnight census as of 4/8/24 is documented as 90. On 4/08/24 at 9:00AM, [NAME] slaw, whipped topping, and sour cream were observed in the refrigerator not labeled with a date or the time in which they were opened. At this same time, (V21), Dietary Manager stated I can't say how long these items have been in the refrigerator since they are not labeled. I will discard them. Food items should definitely be labeled with the date and time opened before being placed in the refrigerator.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain orders for oxygen, failed to store, change, and label oxygen and nebulizer tubing in accordance with facility policy (R16, R19, R26) and failed to provide routine cleaning of a humidifier (R15). R15, R16, R19, R26 are four of five residents reviewed for respiratory care in the sample list of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement enhanced barrier precautions as recommended by the Centers for Disease Control and Prevention. This failure affects five (R31, R97, R149, R150, R33) of five residents reviewed for enhanced barrier precautions in the sample list of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess for the ability to self administer medications for three (R37, R97, R101) of three residents reviewed for self administration of medication in the sample list of 31.

Inspectors wroteBased on interview and record review the facility failed to investigate an injury of unknown origin for one (R16) of three residents reviewed for accidents in the sample list of 31.

Inspectors wroteBased on record review and interview the facility failed to conduct careplan meetings for one of one residents (R21) reviewed for careplan meetings in the sample list of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to document and follow up on a change in condition for one (R28) of 14 residents reviewed for change in condition in the sample list of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a comprehensive wound assessment for new pressure injuries for two residents (R149, R150) of three residents reviewed for pressure ulcers in a sample list of 31. Findings Include: 1. R150's Nursing admission History dated 3/15/24 at 6:08PM documents R150 was cognitively intact and required staff assistance for transfer and Activities of Daily Living (ADLs) and R150's skin was intact. R150's Minimum Data Set (MDS) dated [DATE] documents R150 has two Stage II pressure Ulcers. R150's Order Summary printed 4/10/24 at 4:03PM includes a physician's order originating 3/27/24 for Right buttock open area: Cleanse with Normal Saline, apply hydrocolloid every evening shift every 3 day(s). This order summary also documents a physician's order originating 4/9/24 for Left buttock open area: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen canisters were secure (R101), thoroughly investigate falls, and care plan and implement fall interventions (R5). R101 and R5 are two of three residents reviewed for accidents in the sample list of 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform complete urinary catheter care, failed to prevent cross contamination during urinary catheter care, and failed to maintain the urinary collection bag in a dignity bag and off the floor for three residents (R33, R31, R97) of four residents reviewed for catheter care in a sample list of 31 residents. Findings Include: 1. R33's Physician's Orders for 4/1/24 to 4/30/24 document a Physician's order for urinary catheter care daily and as needed. On 4/10/24 at 11:00 AM V22, Certified Nurse's Aide (CNA) and V23 Certified Nurse's Aide (CNA) proceeded to perform catheter care for R33. R33 was wearing a pull up style incontinence garment. R33 had a bowel movement prior to care. V23 retracted R33's foreskin and cleaned R33's penis from tip to base. V23 cleansed the catheter tubing from insertion site downward. [...]

Inspectors wroteBased on interview and record record review the facility failed to complete/accurately complete psychotropic medication assessments, quantify behaviors to justify the use of psychotropic medication, and attempt nonpharmacological interventions for behaviors for two residents (R14,R5) of five residents reviewed for psychotropic medications in a sample list of 31 residents. 1.) R5's Order Summary Report dated 4/10/24 documents R5 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Major Depressive Disorder, Delusional Disorder, and Paranoid Personality Disorder. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain documentation of immunization status, and offer/administer Pneumococcal and Influenza (Flu) Vaccines for three (R31,R21,R26) of five residents reviewed for immunizations in the sample list of 31.

Inspectors wroteBased on record review and interview the facility failed to offer and administer COVID-19 vaccination boosters to two (R31, R21) of five residents reviewed for COVID-19 vaccinations in a sample list of 31 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to utilize the safest assistive devices for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure resulted in (R1) slipping from a sit to stand lift and sustaining a dislocated shoulder requiring closed reduction. Findings Include: 1. R1's Care Plan updated 3/5/24 includes the following diagnoses: Fall, Chronic kidney Disease Type III, Congestive Heart Failure, Muscle Weakness, Difficulty Walking, Unsteadiness on Feet, Abnormal Gait, Lack of Coordination, and Abnormal Postures. This Care Plan documents R1 is High Risk for Falls. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired, has functional limitations to all four extremities, uses a manual wheelchair and is totally dependent to roll wheelchair 150 Feet. [...]