Westminster Village Health

Inspectors wroteBased on observation, interview and review of other facility documentation it was determined that the facility failed to have a functioning call bell system.

Inspectors wroteBased on observation, record review and interview it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards.

Inspectors wroteBased on record review and interview, it was determined that for one (R16) out of one resident reviewed for accidents, the facility failed to notify a physician of a significant injury of unknown source that was determined to be a right fifth toe fracture.

Inspectors wroteBased on interview and record review, it was determined that for one (R16) out of four residents reviewed for accidents, the facility failed to report an injury of unknown source in timely manner.

Inspectors wroteBased on record review and interview it was determined that for one (R8) out of two residents reviewed for limited ROM the facility failed to develop a care plan that addressed the residents limited ROM and interventions to prevent further contractures.

Inspectors wroteBased on record review and interview it was determined that for one (R67) out of two new admissions reviewed the facility failed to adhere of standards of practice when the initial care plan and admission assessment were not completed by a Registered Nurse.

Inspectors wroteBased on interview and record review, it was determined that for one (R67) out of three residents reviewed for hydration, the facility failed to offer sufficient hydration.

Inspectors wroteBased on observation, interview and record review it was determined for one (R31) out of one resident sampled for respiratory care the facility failed to provide professional standards of practice by ensuring R31's BiPap equipment was stored in a protective plastic bag when not in use.

Inspectors wroteBased on record review and interview it was determined that for one (R7) out of five residents reviewed for unnecessary medication review the facility failed to adequately complete monitoring for side effects of a resident on psychotropic medications.

Inspectors wroteBased on record review and interview it was determined that for one (R20) out of three residents reviewed for transmission-based precautions the facility failed to ensure that a physician was notified promptly of laboratory results.

Inspectors wroteBased on record review and interview it was determined that for one (R20) out of three residents reviewed for transmission-based precautions the facility failed to ensure that laboratory reports were filed in the clinical record.

Inspectors wroteBased on record review and interview it was determined that for two (R1 and R20) out of five residents reviewed for immunizations the facility failed to offer pneumococcal vaccination as required.

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation it was determined that for one (R1) out of four residents sampled for wandering and elopement the facility failed to ensure adequate supervision to prevent R1 from eloping putting the resident at serious immediate jeopardy and risk of a serious adverse outcome. R1, a resident that was confused was able to elope from the facility on 9/27/25 by climbing out of the window in R1's room. R1 walked across the facility's back parking lot and then proceeded to walk across a busy roadway to an area where there was a raised curb, a sloped hill with trees, shrubs and brush. R1 was missing for seven minutes. An immediate jeopardy (IJ) was identified starting on 9/27/25. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents.

Inspectors wroteBased on record review and interviews, it was determined for three (R16, R32, and R217) out of eighteen residents in the investigative sample, the facility failed to ensure the MDS was accurate.

Inspectors wroteBased on record review and interview, it was determined that for one (R37) out of eighteen residents reviewed in the investigative sample, the facility failed to ensure that the required interdisciplinary team (IDT) members participated in the care plan meetings.

Inspectors wrote2. Review of R27's clinical record revealed: 12/5/22 - R27 was admitted to the facility. 12/21/22 - A physician's order was written for midodrine HCL 2.5 mg one tablet by mouth three times a day before meals. Alert please note parameters: hold for systolic blood pressure (SBP) greater than 130. 11/2023 - A review of the November 2023 MAR revealed that on 11/5/23 R27 documented a blood pressure listed of 152/81 and a signature indicating midodrine medication was administered. 11/1/23 - 11/16/23 - A consultant pharmacist's medication regimen review documented that R27 recommendation to read parameters closely for holding midodrine. Order is to hold midodrine for SBP greater than 130 but dose is documented as administered on November 5 at 9:00 AM when blood pressure is 152/81. [...]

Inspectors wroteBased on observation, interview and record review it was determined that for two (R21 and R37) out of two residents reviewed for incontinence, the facility failed to provide services to restore bowel and bladder continence.

Inspectors wroteBased on observation and interviews, it was determined that for one (R47) out of eight residents sampled for food the facility failed to follow menu requests.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Review) that included time frames for different steps in the MRR process.

Inspectors wroteBased on record review and interviews, it was determined that for one (R1) out of three residents reviewed for Abuse, the facility failed to implement their written abuse policy by failing to notify R1's physician of the abuse allegation.

Inspectors wroteBased on record review and interviews, it was determined that for two (R1, R3) out of three residents reviewed for Abuse, the facility failed to report an allegation of abuse within the 2 hour time frame. For R1, the incident alleging sexual assault was reported to staff on 9/9/24 at approximately 11 PM but was not reported to the State Agency until 9/10/24 at 1:18 PM. For R3, the incident alleging emotional abuse was reported to the facility on 4/4/24 at 11 AM but was not reported to the State Agency until 4/8/24 5:18 PM.

Inspectors wroteBased on observation, interview and record review, it was determined that for three (R71, R68 and R43) out of six residents reviewed for abuse, the facility failed to ensure that R71, R68 and R43 were free of sexual abuse by R16, a resident with a history of sexually inappropriate behavior. The facility's failure to monitor R16 allowed the sexual abuse of R71 on 9/14/22, R68 on 11/16/22 and R43 on 12/16/22. An Immediate Jeopardy (IJ) was identified starting 9/14/22. Due to the facility's corrective measures following the last incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 12/16/22.

Inspectors wroteBased on interview and record review, it has been determined that for two (R10 and R21) out of five residents sampled for unnecessary medication review, the facility failed to ensure the physician reviewed and signed the consultant pharmacist communication. In addition, the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Reviews) that included time frames for different steps in the MRR process.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure safe, sanitary storage of food and maintain food preparation equipment in a sanitary and safe operating condition.

Inspectors wroteBased on record review and interview, it was determined that for one (R5) out of forty (40) sampled residents for resident assessment, the facility failed to accurately assess an unstageable pressure ulcer/injury due to an eschar on R5's left lateral heel.

Inspectors wrote2. Review of R10's clinical record revealed: 6/23/22 - Review of R10's PASARR Level I screen outcome documented . 1. No level II required . 2. No SMI (serious mental illness), ID (intellectual disability) or RC (related condition). In addition, R10's PASARR Level I screen documented R10 did not have a diagnosis and or neurocognitive disorder. 6/28/22 - A review of R10's medical diagnosis sheet revealed R10 was admitted with a diagnosis of psychosis, anxiety, and dementia. 10/18/23 11:07 AM - E4 (SW) was interviewed and stated, R10 had a PASARR dated 6/23/22 and was admitted on [DATE]. E4 revealed I'm not sure if a PASARR Level II was done, I'll need to check. 10/18/23 1:55 PM - E4 presented a preadmission PASARR Level I screen for R10 and stated, I don't know why another PASARR had not been done, it just slipped off the radar. [...]

Inspectors wroteBased on interview and record review it was determined that for two (R5 and R36) out two residents reviewed for pressure ulcers (PU), the facility failed to provide necessary treatment and services to promote healing. For R5, the facility failed to remove an orthopedic boot that was identified as a possible cause of preventing the healing of a pressure ulcer. For R36, the facility failed to apply the air-filled heel off-loading boots.

Inspectors wroteBased on interview and record review, it was determined that for one (R57) out of three residents reviewed for range of motion, the facility failed to ensure R57 received services to maintain functional ability and to prevent contractures.

Inspectors wroteBased on record review and interview, it was determined that for one (R368) out of six residents reviewed for accidents, the facility failed to provide adequate supervision during a mechanical lift transfer.

Inspectors wroteBased on record review and interview it was determined that for one (R56) out of one resident reviewed for incontinence the facility failed to respond to or provide services to restore bladder continence after a decline in bladder continence was identified.

Inspectors wroteBased on interview and review of facility documentation, it was determined that the facility failed to ensure that a performance review was completed at least every 12 months for three (E8, E9 and E10) out of five sampled employees.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that medications were stored and labeled properly in two out of three medication carts reviewed. Finding's include: The facility policy on storage of medications, last updated May 2018 indicated, .Medications and biologicals are stored safely, securely, and properly, following manufacturers' recommendations or those of the supplier . 10/16/23 12:14 PM - During a medication storage review of the 200 hall the following was observed inside the 200 hallway medication cart: - One opened bottle of laxative with no open date. - One opened vial/pen of insulin labeled 'discard unused after 28 days' with no open date. 10/16/23 12:24 PM - E14 (LPN) confirmed the findings. 10/16/23 12:39 PM - During a medication storage review of the 400 hall the following was observed inside the 400 hallway medication cart: [...]