Westminster Point Pleasant

Based on observations, staff interviews and facility record review, the facility failed to operate and maintain the dish washing machine per manufacturer's specifications related to the wash cycle not meeting temperature requirements for one machine of one dish washing machine observed. Findings included: During a kitchen tour on 8/11/2025 at 9:49 a.m., the Kitchen Manager indicated the facility operates a High temperature type dish washing machine and revealed the wash should reach at least 160 degrees Fahrenheit (F.) and a final rinse should reach 190 degrees F. He revealed all staff in the kitchen are trained on how to operate the machine and log temperatures. Review of the specification plate on the dish machine revealed the machine was operating as a high temperature dish washing machine and the wash temperature should reach 160 degrees F., and the Rinse temperature should reach 180 degrees F. The Kitchen Manager confirmed the machine's operations specificationsOn 8/11/2025 at 9:52 a.m., the Kitchen Manager and Staff K, Dining Services Technician, both confirmed they had been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to formulate an advance directive and did not ensure a current copy was in the resident's medical record for one resident (#45) of twenty-six residents sampled.Findings included: Review of the admission record revealed Resident #45 was admitted to the facility on [DATE]. Review of the advanced directives revealed the resident was a FULL CODE status and did not have documentation for the designated POA (Power of Attorney) and the primary decision-maker for care. Review of an admission MDS (Minimum Data Set) assessment, dated 7/17/2025, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) assessment that was not scored, but revealed short-term (ST)/long-term (LT) memory problems with Severely Impaired Decision-Making Skills. An interview was conducted with Staff G, a social worker, on 08/12/2025 at 2:50 p.m. She reviewed the social assessment form that was completed for Resident #45. The form was completed by the resident's spouse on July…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete and update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with qualifying mental health diagnoses for two residents (#3 and #10) of 6 residents reviewed for PASARRs. Findings included: Review of the admission record showed Resident #10 was admitted to the facility on [DATE] with a primary diagnosis of dementia on – 4/14/23 and secondary diagnoses with onset dates, mood disorder - 4/14/23, depression - 4/14/23 irritability and anger - 4/14/23 bipolar - 4/14/23 anxiety - 4/14/23 and failure to thrive - 4/14/23. Review of a level I PASARR for Resident #10 dated 5/28/24 revealed all the qualifying diagnoses were not checked. The review showed the Level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. Review of the admission record showed Resident #3 was admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction on – 2/19/25 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed ensure timely assistance with Activities of Daily Living (ADLs) consistent with the assessed and care planned toileting needs for one resident (#48) of three residents sampled.Findings included: On 8/12/ 2025 at 11:30 a.m., Resident #48 was observed lying down in bed, with no signs of distress. The resident reported concerns with his care because a couple of days ago he was placed on a bed pan and left on it for approximately 45 minutes. An interview was conducted on 08/13/2025 at 2:36 p.m. with Resident #48 stating having had to wait about two hours to receive assistance after being placed on the bed pan. He said Staff T, certified Nursing Assistant (CNA) came to his room around 8:00 a.m. and told the resident she was not able to assist him because she could not find his bed pan and she had to go to the dining room. He said he waited for about 15 minutes then he put his call light back on. Another unidentified CNA answered the call light,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide meal assistance for two residents (#39 and #45) of thirty-four sampled residents during two of three meal observations on 8/11/2025 and 8/13/2025. Findings included: 1.8/11/2025 at 12:30 p.m. Resident #39 was observed seated in the third-floor dining room at a table and with two other residents. By 12:34 p.m. the other two table mates were served and set up with their lunch meal tray. A staff member was observed to serve one of the three residents at the same table and sat down in a chair and proceeded to assist that resident with eating activities. Resident #39 was still observed at the table and had no meal tray in front of her. The other two were eating as Resident #39 watched. Resident #39 was observed to fall asleep twice but would open her eyes from time to time and looked at her table mates. Resident #39 was not interviewable and would not be able to answer questions related to her medical care and day’s activities. At…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Thirty-two medication opportunities were observed, and six errors were identified for Resident #29 resulting in an error rate of 18.75%.Findings included: On 8/11/25 at 10:45 a.m., Staff P, Registered Nurse (RN) was observed administering medications to Resident #29. Staff P, RN administered the following medications: Pregabalin 25 mg, Amlodipine 5 mg, Aspirin 81mg, Zoloft 50 mg, Potassium chloride ER 10 meq and Tamsulosin 0.4 mg. Following the medication administration observation, a review of Resident# 29's Medication Administration Record (MAR) revealed the Pregabalin, Amlodipine, Aspirin, Zoloft, Potassium Chloride, and Tamsulosin was scheduled to be administered at 9:00 a.m.On 8/13/25 during an interview Staff O, Licensed Practical Nurse (LPN), said nurses are allowed to administer medications between one hour before and one hour after the scheduled medication administration time. On 8/13/25 at 2:56 p.m. during an interview the Director of Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to implement timely their Abuse, Neglect and Exploitation policy and procedure related to reporting alleged abuse and neglect incidents for three residents (#1, #2, and #3) of three sampled for Abuse and Neglect. Findings included: 1. A review of the facility's Abuse Log showed Resident #1 had an incident, date notified of allegation was on 05/15/2025, reported to DCF (Department of Children and Families) on 05/15/2025. The incident was documented as Yes to being substantiated, and Yes it was an adverse related to Resident #1 did not receive medications for two days, which was communicated immediately to the Abuse Coordinator on 05/10/25, the date the event started. A review of Resident #1's admission Record documented an admission to the facility on [DATE]. Review of a progress note dated 05/08/2025 showed Resident #1 was transferred to a local hospital on [DATE] at 1312 (1:12 p.m.), for an evaluation and subsequently returned on 05/08/2025 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure care planning interventions were implemented related to; 1) Not providing adaptive eating equipment during meal service, and 2) Not offering and assisting with braces/splinting for contracture management for two residents (#83 and #36) out of twenty-two sampled residents. Findings included: 1) On 4/24/2023 at 12:40 p.m. Resident #83's room was approached and from the hallway, the resident could be seen in his room seated in a high-back wheelchair next to his bed, with the over the bed table positioned in front of him. The resident was noted to be alone in the room with his meal tray placed in front of him. The floor beneath him was observed with what appeared to be a puddle of red liquid. The resident was able to confirm he had dropped some liquid on the ground. Resident #83 was interviewed; he was noted to have to take time to answer general questions about his day. The resident was noted to have some food pocketed within his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure eating assistance and adaptive eating equipment was provided for one resident (#83) out of twenty-two sampled residents. Findings included: On 4/24/2023 at 12:40 p.m. Resident #83's room was approached and from the hallway, the resident could be seen in his room seated in a high-back wheelchair next to his bed, with the over the bed table positioned in front of him. The resident was noted to be alone in the room with his meal tray placed in front of him. The floor beneath him was observed with what appeared to be a puddle of red liquid. The resident was able to confirm he had dropped some liquid on the ground. Resident #83 was interviewed; he was noted to have to take time to answer general questions about his day. The resident was noted to have some food pocketed within his mouth on both sides. While in the room with Resident #83 from 12:40 p.m. through to 12:52 p.m., no staff were observed to enter the room to assist the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to provide care consistent with professional standards of practice related to following physician orders for oxygen therapy for one resident (#52) out of two sampled residents for respiratory care. Findings included: A review of the admission Record for Resident #52 showed she was initially admitted into the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation and chronic respiratory failure with hypercapnia. A review of the Minimum Data Set (MDS) assessment, dated 04/11/23, revealed in Section C Cognitive Patterns, Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15 out of fifteen indicating cognitively intact. Section O Special Treatments, Procedures, and Programs indicated Resident #52 was on oxygen while a resident. A review of the Order Summary Report with active orders as of 04/27/23 revealed the following order: -continuous oxygen at 2 liters per minute via…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of facility policy, the facility failed to ensure proper labeling and storage of drugs and biologicals for two (Resident #77 and Resident #66) of eight residents observed for medication administration, in three of three medication carts observed, and in one of two medication storage rooms observed. Findings included: A medication cart inspection was conducted on 05/26/21 at 10:56 a.m. with Staff F, Licensed Practical Nurse (LPN) on the 200 unit of the facility. A container of glucose monitoring test strips was observed in the top drawer of the medication cart. The glucose monitoring test strips did not have a date labeled on them to indicate when they were opened. Staff F, LPN was not able to state whether or not the glucose monitoring test strips should have been dated upon opening and stated that she would not normally put a date on the bottle. Two small brown bottles of Nitroglycerin 0.4 milligram (mg) tablets was observed in the medication cart. One of the small…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and policy review, the facility failed to follow their policy to appropriately store and maintain food in for a safe and sanitary manner in one of four refrigerators and one freezer. Findings included: During the initial kitchen tour on 05/29/2021 at 9:30 a.m., an observation of the freezer revealed two large white plastic buckets of cornbread batter on the floor of the freezer. The Certified Dietary Manager (CDM) confirmed the presence on the floor, and indicated they need to be stored on a shelf. The CDM further indicated that they were moved there due to inventory process and placed each bucket on the bottom shelf. Observation of the walk-in refrigerator included on the side second shelf, a cardboard box that contained two moldy lemons. On the first shelf at the back of the refrigerator, a large bottle was seen without a cover, that contained garlic. The CDM, confirmed the presence of both moldy lemons, and asked an unidentified kitchen staff to remove the bottle of garlic, that she quickly threw away into a nearby garbage receptacle.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.