A list of the most recent deficiencies for Westminster Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-09-21 | 2023-11-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-21 | 2023-11-05 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-09-21 | 2023-11-05 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-21 | 2023-11-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-21 | 2023-11-05 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-09-21 | 2023-11-05 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-09-21 | 2023-11-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-21 | 2023-11-05 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-09-21 | 2023-11-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-09-21 | 2023-11-05 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-09-21 | 2023-11-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-21 | 2023-11-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-21 | 2023-11-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-21 | 2023-11-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-21 | 2023-11-05 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-09-21 | 2023-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-21 | 2023-11-05 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-09-21 | 2023-11-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-21 | 2023-11-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-21 | 2023-11-05 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-21 | 2023-11-05 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-21 | 2023-11-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-21 | 2023-11-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-21 | 2023-11-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-21 | 2023-11-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-11-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-21 | 2023-11-05 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-21 | 2023-11-05 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-09-21 | 2023-11-05 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-21 | 2023-11-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-21 | 2023-11-05 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-21 | 2023-11-05 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-21 | 2023-11-05 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-09-21 | 2023-11-05 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-21 | 2023-11-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-21 | 2023-11-05 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-09-21 | 2023-11-05 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-30 | 2023-09-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-30 | 2023-09-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-08-30 | 2023-09-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-22 | 2021-11-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-22 | 2021-11-03 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-09-22 | 2021-11-03 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-09-22 | 2021-11-03 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-09-22 | 2021-11-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-22 | 2021-11-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-22 | 2021-11-03 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-22 | 2021-11-03 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-09-22 | 2021-11-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-22 | 2021-11-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-22 | 2021-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-22 | 2021-11-03 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-09-22 | 2021-11-03 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-09-22 | 2021-11-03 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-09-22 | 2021-11-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-22 | 2021-11-03 | Y |
| Post nurse staffing information every day. | Health | 2021-09-22 | 2021-11-03 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-09-22 | 2021-11-03 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-22 | 2021-11-03 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-09-22 | 2021-11-03 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2021-09-22 | 2021-11-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-22 | 2021-11-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-22 | 2021-11-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-09-22 | 2021-11-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-07 | 2019-06-21 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-05-07 | 2019-06-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-07 | 2019-06-21 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-05-07 | 2019-06-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-05-07 | 2019-06-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-05-07 | 2019-06-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-05-07 | 2019-06-21 | N |
| Respond appropriately to all alleged violations. | Health | 2019-05-07 | 2019-06-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-07 | 2019-06-21 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-05-07 | 2019-06-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-05-07 | 2019-06-21 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-05-07 | 2019-06-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-07 | 2019-06-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-07 | 2019-06-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-07 | 2019-06-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-07 | 2019-06-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-07 | 2019-06-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-05-07 | 2019-06-21 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-05-07 | 2019-06-21 | N |
| Provide activities to meet all resident's needs. | Health | 2019-05-07 | 2019-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-07 | 2019-06-21 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-05-07 | 2019-06-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-07 | 2019-06-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-05-07 | 2019-06-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-07 | 2019-06-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-05-07 | 2019-06-21 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-05-07 | 2019-06-21 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-05-07 | 2019-06-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-05-07 | 2019-06-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-07 | 2019-06-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-05-07 | 2019-06-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-07 | 2019-06-21 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-05-07 | 2019-06-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-05-07 | 2019-06-21 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-05-07 | 2019-06-21 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-05-07 | 2019-06-21 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-05-07 | 2019-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-07 | 2019-06-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-07 | 2019-06-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-05-07 | 2019-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-07 | 2019-06-21 | N |
| Keep all essential equipment working safely. | Health | 2019-05-07 | 2019-06-21 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-05-07 | 2019-06-21 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-04-08 | 2019-04-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-11-03 | 2017-12-12 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-11-03 | 2017-12-12 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-11-03 | 2017-12-12 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-11-03 | 2017-12-12 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-11-03 | 2017-12-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-11-03 | 2017-12-12 | N |
| Provide housekeeping and maintenance services. | Health | 2017-11-03 | 2017-12-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2017-11-03 | 2017-12-12 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-11-03 | 2017-12-12 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-11-03 | 2017-12-12 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-11-03 | 2017-12-12 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-11-03 | 2017-12-12 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-03 | 2017-12-12 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-11-03 | 2017-12-12 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-11-03 | 2017-12-12 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-11-03 | 2017-12-12 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-11-03 | 2017-12-12 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-11-03 | 2017-12-12 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-11-03 | 2017-12-12 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-03 | 2017-12-12 | N |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-11-03 | 2017-12-12 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-11-03 | 2017-12-12 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-03 | 2017-12-12 | N |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2017-11-03 | 2017-12-12 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-11-03 | 2017-12-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-11-03 | 2017-12-12 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-11-01 | 2017-12-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-11-01 | 2017-12-06 | N |
