Westminster Health & Rehab Center

Based on observation, interview, and facility policy review, the facility failed to ensure raw meat was stored properly in the walk-in refrigerator. This deficient practice had the potential to affect all 6 residents who currently resided in the facility.Findings included:Review of the facility policy titled, Food and Supply Storage, revised 01/2026, indicated, Separate cooked and raw foods. Store ready-to-eat (including pasteurized eggs) and cooked food above raw food. If raw animal foods are stored on the same rack, store them in the following order from top of the rack to the bottom of the rack: raw shell eggs, fish, whole cuts of beef, pork, ground meat and poultry.During a concurrent interview and observation of the walk-in refrigerator in the kitchen on 02/23/26 at 10:28 AM with the Administrator and Clinical Dietician, there were three boneless pork tenderloins located on the second shelf above a covered bowl of coleslaw and a covered bowl of fruit cocktail. Also, there was 15 pounds of raw bacon above some tomatoes. The Clinical Dietician stated the raw pork tenderloin…

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, record review, and facility policy review, the facility failed to ensure transfer and discharge notifications were sent to a representative of the State Long Term Care (LTC) Ombudsman for 2 (Resident (R)6 and R8) of 2 sampled closed records reviewed. Findings included: A facility policy titled, Transfer or Discharge Notices, revised 03/2025, indicated, 3. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. 4. Notice of the State LTC Ombudsman will occur at the same time as the notice of discharge is provided to the resident and resident representative. 1. A Resident Face Sheet revealed the facility admitted R8 on 11/06/25. According to the Resident Face Sheet, the resident discharged home on [DATE]. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/15/25, revealed R8 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS…

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, record review, and facility policy review, the facility failed to ensure their medication error rate was not greater than 5 percent (%). There were 2 errors out of 29 opportunities, which resulted in a medication error rate of 6.9% for 2 (Resident (R)9 and R11) of 3 residents observed for medication administration. Findings included:A facility policy titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame.1. A Resident Face Sheet indicated the facility admitted R9 on 12/01/25. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of allergic rhinitis.R9's Physician Order Report, for the timeframe 01/25/26 - 02/25/26, revealed an order dated 11/18/25, for Flonase allergy relief 50 micrograms (mcg) per actuation (spray), administer two sprays to each nostril once a day.During medication administration observation on 02/23/2026 at 3:34 PM, Registered Nurse (RN)1 prepared and administered R9's…

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, record review, and interview, the facility failed to prevent potential accidents related to over the counter (OTC) medication's being at bedside for Resident (R)1, for one of one resident reviewed for accidents hazards. Findings include: Review of the facility's policy titled, Medication Administration Record copyrighted 2001, revealed, Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation . 24. Topical medications used in treatments are recorded on the resident's treatment record (TAR) . 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safety. Review of the facility's policy titled, Self-Administration of Medications version 09/2020, revealed, The facility shall permit residents who are competent and physically able to self-administer their medications if the following conditions are met: 1. Self-administration of medications by…

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 review of facility policy, observation and interview, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance to professional standards including expiration dates, for 1 of 1 treatment cart. Findings include: Review of the facility's policy titled Medication Storage (SC SNF Pharmacy Policy and Procedure Manual), version 09/2020, did not reveal information on professional standards of on labeling, expiration dates, or discarding expired medications. During an observation on 03/18/25 at 12:46 PM, the treatment cart revealed the following: One Hydrofera Blue 10.2cm x 10.2 cm 4x4 Sterile, Ref# HB4414, Lot # 190328150, exp 02/01/2024. Aloe cream, LOT #313, Manufacturer Rugby Laboratories, expired 11/24. Two sterile suture removal kits, Manufacturer Dynamex Corporation, Lot #51842, expired 01/04/2025. Thirty sterile wood shaft cotton tipped applicators, Ref #76800, Manufacturer ProAdvantage by NDC, Lot #91504, expired 02/2024. The expired medications was verified and removed by Registered Nurse (RN)1. During an interview on…

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 review of facility policy, observation and interview, the facility failed to ensure an excessive amount of lint was removed from 2 of 2 clothes dryers. The lint was noted above and behind the lint basket and on the 3 inside walls of the clothes dryers. Findings include: Review of a facility document titled, Laundry Assistant/ Equipment and Supply Functions states, . clean the lint screen for each commercial dryer at a minimum of each shift and when necessary. During an observation on 03/19/25 at 12:13 PM, of two dryers revealed the lint baskets and three walls below the dryers contained an excessive amount of lint. During an observation on 03/19/25 at 12:20 PM, the signage posted on 1 of 2 dryers stated, Clean Lint Filters, Remove Lint from the Dryer Lint Screens Every Time You Use the Dryer. This Helps Prevent A Fire, But It Also Helps Laundry To Dry Faster. During an interview and observation on 03/19/25 at 12:33 PM, the Environmental Services Supervisor (ESS) confirmed the excessive amount of lint. The ESS stated that the laundry staff removes the lint from the lint…

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, record review, and facility's policy review, the facility failed to ensure one resident (Resident (R)5) of nine sampled residents, did not self-administer her inhalant nebulizer medication without an assessment and physician's order to self-administration the medication. The facility's deficient practice increased R5's risk for adverse medication reactions. Findings include: Review of facility policy titled Self-Administration of Medication, 12/12, revealed .Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so .As a part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications .The staff and practitioner will document their findings and the choices of residents who are potentially capable of self-administering medications . Review of the facility's policy titled Administering Medications, 12/12, revealed .Medications shall be…

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, review of records, and review of facility policies, the facility failed to ensure: 1. a physician's order was obtained for blood sugar fingersticks for two residents ((R)4 and R2); and 2. R4's insulin physician's orders were correct on the Medication Administration Record (MAR) out of five residents sampled for unnecessary medications. Findings include: Review of facility's policy titled Insulin Administration, dated 09/14 and provided by the Administrator, revealed .To provide guidelines for the safe administration of insulin to residents with diabetes .The type of insulin, dosage requirements . Must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .The nurse shall notify the Director of Nursing Services and Attending Physician of any discrepancies, before giving the insulin .Documentation .The resident's blood glucose result, as ordered . Review of facility's policy titled Obtaining a Fingerstick Glucose Level, dated 10/11 and provided by the Administrator, revealed…

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.