Westminster Winter Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer Oxygen (O2) therapy as ordered by the physician for 2 of 4 residents reviewed for respiratory care, of a total sample of 4 residents, (#3 and #4).1. Resident #3 was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory failure, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF).Review of resident #3's medical record revealed a care plan revised on 8/07/25 which indicated the resident's oxygen to be applied, as ordered by physician, for respiratory complications related to CHF, COPD, and pneumonia.Supplemental oxygen therapy helps people with COPD, COVID-19, emphysema, sleep apnea and other breathing problems get enough oxygen to function and stay well. Low blood oxygen levels (hypoxemia) can damage organs and be life-threatening, (retrieved on 8/15/25 from www.myclevelandclinic.org).Resident #3's Order Summary Report showed an active physician's order dated 8/4/25 for…

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 interview, and record review, the facility failed to honor residents' rights to choose their preferred bathing preferences for 1 of 2 residents reviewed for choices, of a total sample of 29 residents, (#55). Findings: Review of the medical record revealed resident #55 was admitted to the facility on [DATE] from the hospital. His diagnosis included Parkinson's disease, osteoarthritis, right hip pain, and bilateral inguinal hernia. Resident #55's admission Minimum Data Set with an assessment reference date of 10/16/24 revealed the resident scored 14 out of 15 on the Brief Interview for Mental Status, indicating he had no cognitive impairment. The MDS assessment also indicated resident #55 was dependent on bathing; it was somewhat important for him to choose between a shower and bed bath, and he participated in the assessment and goal setting. The assessment also revealed the resident did not exhibit behavior symptoms or rejection of care necessary to achieve the resident's goals for health and well-being.…

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 interview, and record review, the facility failed to provide a written summary of the Baseline Care Plan as required for 1 of 2 residents reviewed for Care Planning, of a total sample of 29 residents, (#869). Findings: Resident #869, an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included sepsis, atrial fibrillation, hypertension, generalized muscle weakness, hyperlipidemia, and a personal history of pneumonia. On 10/28/24 at 12:20 PM, resident #869 stated she was admitted to the facility for therapy, had been at the facility since 10/24/24, had not had any therapy, and did not know about or have a copy of her care plan. The resident said she did not think she signed anything regarding her plan of care. Review of the resident's clinical records revealed a Baseline Care Plan which indicated resident #869's admission date was 10/24/24. The summary and signatures areas, revealed the document was not signed until 10/28/24 by the resident and the Unit Manager . On 10/29/24 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 interview, and record review, the facility failed to ensure resident and/or their representative were invited/involved in the development of their care plan for 1 of 2 residents reviewed for care planning, of a total sample of 29 residents, (#38). Findings: Resident #38, an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included malignant neoplasm of unspecified left bronchus or lung, dementia, diabetes type II, chronic diastolic (congestive) heart failure, chronic atrial fibrillation, hypertension, anxiety disorder and cardiomegaly. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was intact, with a Brief Interview For Mental Status score of 15 out of 15. Section F for preference of the resident's annual MDS dated [DATE] revealed it was very important for the resident to have family/close friend involved in discussion about her care. On 10/28/24 at 4:42 PM, resident #38 stated she had not attended any care…

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 observation, interview, and record review, the facility failed to provide sufficient licensed nurses on the 7:00 AM to 3:00 PM shift to meet medication administration needs, according to plans of care for residents on 2 of 2 floors (1st and 2nd floors); and failed to ensure sufficient Certified Nursing Assistants (CNAs) to meet person-centered needs for repositioning and incontinence care for 3 of 4 residents reviewed for activities of daily living (ADLs), out of a total sample of 27 residents, (#2, #5, and #7). Findings: 1. On 5/16/24 at 10:27 AM, Registered Nurse (RN) E explained she was administering scheduled 8:00 AM and 9:00 AM medications and still had twelve other residents on her assignment who had not yet received morning medications. She stated her assignment was split between two hallways and the other 1st floor nurse, Licensed Practical Nurse (LPN) C, had additional residents on the 2nd floor. She explained there were three nurses for both floors. When asked if split assignments across units…

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 record review, the facility failed to provide pharmaceutical services to ensure timely medication administration in accordance with its policies, procedures and accepted standards of practice for 25 residents reviewed for medication administration, out of a total sample of 27 residents, (#3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27). Findings: On 5/16/24 at 10:27 AM, Registered Nurse (RN) E stood at her medication cart on the 1st floor. Her computer screen displayed several residents' profiles in red and she explained the color indicated their scheduled morning medications were now late. RN E stated she had four residents left on one hallway and eight on the back hallways. She confirmed the twelve residents left all had medications scheduled for 8:00 AM and/or 9:00 AM. RN E explained her assignment was split between two hallways and the other 1st floor nurse, Licensed Practical Nurse (LPN) C's assignment was split between the 1st and 2nd floors. RN E verified late…

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 interview and record review, the facility failed to notify the physician and/or resident representatives of changes in condition related to development of a pressure ulcer and performance of a surgical procedure for 1 of 4 residents reviewed for pressure injuries, of a total sample of 27 residents, (#5). Findings: Review of the medical record revealed resident #5, a [AGE] year-old female, was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included metabolic encephalopathy (brain disorder), altered mental status, non-traumatic bleeding inside the brain, right carotid artery occlusion, left side weakness and paralysis, and generalized muscle weakness. The Resident Information sheet was updated to show the resident acquired a Stage III pressure ulcer during her stay in the facility. The document indicated resident #5's husband was Power of Attorney (POA) for health care and her daughters were emergency contacts #1 and #2. The National Pressure Injury Advisory Panel (NPIAP)…

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, interviews, and policy and quality assurance audits, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, based on the following: - Clean equipment was not stored in a manner to protect it from contamination. - The dish machine hot water pressure gauge was not reaching 20 PSI (Pounds per Square Inch) pressure, as required, to ensure multi-use equipment was properly washed and sanitized. - Bulk ready-to eat, non-Time/Temperature Control for Safety (TCS) food was not properly labeled to its identity. - Employees were using beverage containers in the kitchen that were not designed to be handled to prevent contamination of the employee's hands and container. - Cold and hot TCS foods were not held at proper temperatures (41 degrees Fahrenheit or less/135 degrees Fahrenheit or more, respectively). - Refrigerated ready-to eat TCS food was not date-marked to indicate when the date the food must be consumed or discarded. These practices have a potential to affect 77 out of 79 resident who…

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 and interview, the facility failed to dispose of the garbage properly in the facility compactor. The facility compactor was used for the entire campus. Findings: A follow up visit to the kitchen was done on 3/29/23 at 10:55 AM with the Dining Service Director, the facility Registered Dietitian, and the Clinical Nutrition Supervisor. A pile of bagged garbage was noted in the dumpster in front of the compactor (transport bin) and the garbage storage bin was not closed or covered. Additionally, there was an open bin of the compactor that had a pile of bagged garbage that was not covered. The surveyor asked the Dining Service Director how often the compactor was operated and he did not know. There were flies flying around the compactor. Photos taken. On 03/29/23 at 10:57 AM, a letter-sized paper between the compactor and the attached dumpster was observed. The paper appeared to be a resident list. Photographic evidence taken. On 03/30/23 at 12:24 PM, the Dining Service Director stated that he talked to maintenance and the employees were supposed to use the compactor…

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 and interview, the facility failed to provide a homelike environment for all the residents who ate their meals in the first floor dining room (ranging from 11 to 17 residents) at three different meals, by serving the resident's meals on serving trays at the table in an institutional manner. Findings: On 3/27/23 at 11:44 AM, in the first floor main dining room, residents were served from a satellite kitchen with a hot food holding line. When staff assembled the residents' trays, they placed their plates, bowls, cups and eating ware on serving trays. The staff brought the serving trays to the residents' tables and placed them in front of the residents. The staff did not remove the resident's plate and other eating ware from the tray. There were at least 17 residents who had their plates on the serving trays at their tables. During the breakfast meal observation in the first floor dining room on 3/28/23 from 7:39 AM to 8:23 AM, staff served 11 residents their breakfast meals on serving trays and their plates and eating ware were not removed from the trays at 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.

Based on observation, interview, and record review, staff failed to perform proper hand hygiene during two meals observed in the first floor dining area. Staff failure to do proper hand hygiene has a potential to spread infection to the 11 to 17 residents who ate meals in the first floor dining area. Findings: During the lunch observation on 3/27/23 from 11:44 AM to 12:07 PM, none of the five staff assisting with the meal service performed hand hygiene during that time. These staff were involved with serving resident's food, removing soiled trays, and assisting with feeding residents. During a follow-up meal observation on 3/28/23 at 7:39 AM at breakfast, there were initially three staff who were serving meals and none of them performed hand hygiene. They served trays and one of the staff used a pen to write a resident's menu selection. At 3/28/23 at 7:58 AM, one staff got a banana for a resident and did not perform hand hygiene before or after this task. At 3/28/23 at 7:59 AM, CNA, Staff C fed a resident and left to serve another meal tray. There is a stand hand sanitizer dispenser…

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 closed record review and interview, the facility failed to develop a comprehensive care plan for one of one resident, (#82) reviewed for death in the facility. Resident #82 had an identified swallowing problem and the Speech-Language Pathologist had recommended compensatory strategies which were not included in the resident's comprehensive care plan. The resident had a choking incident on 2/10/23, and despite the facility staff and Emergency Medical Services emergency efforts, the resident died. Findings: According to the medical record of Resident #82, he was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. The resident died on 2/10/23. Resident #82 had multiple medical diagnoses, including Parkinson's disease; oropharyngeal phase dysphagia (swallowing problem involving the throat and pharynx); elevated blood cholesterol, high blood pressure, hypothyroidism, atherosclerotic heart disease of the native coronary artery without angina pectoris (heart disease in which…

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.

n observation and interview, the facility failed to ensure 3 residents (#6, #30, and #38) out of 11 to 17 residents eating in the first floor dining room during three different meals, were positioned to maximize eating abilities. Findings: On 3/27/23 at 11:52 AM in the first floor main dining room during the lunch meal, Resident #6 was sitting in a wheelchair at a table and the table was too high. The table top was level with her neck. She was sitting at a table that was lined up with two other tables. On 3/27/23 at 11:53 AM, Resident #30, who was sitting in a wheelchair, was also seated at a table table that was too high for her. The table top was level to her neck. During the breakfast meal observation on 3/28/23 at 8:13 AM in the first floor dining room, Resident #6 was observed sitting at a table that was too high for her. She was sitting in a wheelchair and the table top was level with neck. She was sitting at a table lined up with two other tables. Resident #30 was also sitting at a table too high for her. She was sitting in a wheelchair and the table top was level with neck.…

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.