Deficiency Records for Westminster Healthcare Center
Updated as of August 01, 2023
This is not the most recent data for Westminster Healthcare Center. For the most recent information, click here.
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? |
---|---|---|---|---|
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 receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-02-04 | 2021-04-06 | 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 | 2021-02-04 | 2021-04-06 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-02-04 | 2021-04-06 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-02-04 | 2021-04-06 | Y |
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2020-11-05 | 2020-12-19 | Y |
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 | 2020-11-05 | 2020-12-19 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-11-05 | 2020-12-19 | Y |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-11-05 | 2020-12-19 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-11-05 | 2020-12-19 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-11-05 | 2020-12-19 | Y |
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2020-11-05 | 2020-12-19 | 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 | 2020-11-05 | 2020-12-19 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-11-05 | 2020-12-19 | Y |
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2020-11-05 | 2020-12-19 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-11-05 | 2020-12-19 | Y |
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 | 2020-11-05 | 2020-12-19 | Y |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-11-02 | 2020-11-03 | Y |
Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2020-11-02 | 2020-11-03 | Y |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-11-02 | 2020-11-03 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-09-03 | 2020-10-15 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-09-03 | 2020-10-15 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-09-03 | 2020-10-15 | Y |
Provide enough food/fluids to maintain a resident's health. | Health | 2020-09-03 | 2020-10-15 | Y |
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 | 2020-09-03 | 2020-10-15 | 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 | 2020-09-03 | 2020-10-15 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-09-03 | 2020-10-15 | 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 |
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 | 2017-04-20 | 2017-05-31 | 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 | 2017-04-20 | 2017-05-31 | N |
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-04-20 | 2017-05-31 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2017-04-20 | 2017-05-31 | N |
Provide housekeeping and maintenance services. | Health | 2017-04-20 | 2017-05-31 | N |
Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-04-20 | 2017-05-31 | N |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-04-20 | 2017-05-31 | N |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-04-20 | 2017-05-31 | N |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-20 | 2017-05-31 | N |
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-04-20 | 2017-05-31 | N |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-04-20 | 2017-05-31 | 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 | 2017-04-20 | 2017-05-31 | N |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-04-20 | 2017-05-31 | N |
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-04-20 | 2017-05-31 | N |
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-04-20 | 2017-05-31 | N |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-20 | 2017-05-31 | N |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-20 | 2017-05-31 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-04-20 | 2017-05-31 | N |