Inspection Reports for Westminster Commons
560 St Charles Ave NE, Atlanta, GA 30308, GA, 30308
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 8, 2025, found no deficiencies, and complaint investigations conducted at that time were unsubstantiated. Earlier inspections showed a mixed history, with notable deficiencies identified in the May 22, 2025 annual survey related to resident care planning, medication monitoring, abuse documentation, catheter bag positioning, and side rail use. Prior complaint investigations included one substantiated deficiency for inadequate fall prevention in September 2024, but most complaints were unsubstantiated. Enforcement actions were not listed in the available reports for recent inspections, though earlier years included some enforcement related to advance directive compliance and medication management. The facility appears to have corrected previously cited deficiencies over time, with the most recent surveys indicating improvement in compliance.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
247% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
84 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
A revisit survey was conducted from July 7, 2025, through July 8, 2025, including investigation of two complaint intake numbers GA00255240 and GA00255301.
Complaint Details
Complaint Intake Numbers GA00255240 and GA00255301 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the Revisit/Complaint Survey concluded on May 22, 2025, were found to be corrected. The complaint investigation found both complaints to be unsubstantiated.
Report Facts
Complaint Intake Numbers: 2
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
A revisit survey was conducted from July 7, 2025, through July 8, 2025, in conjunction with investigation of two complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00255240 and GA00255301 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the prior Revisit/Complaint Survey concluded on May 22, 2025, were found to be corrected. The complaint investigation found both complaints to be unsubstantiated.
Report Facts
Complaint Intake Numbers: 2
Inspection Report
Life Safety
Census: 83
Capacity: 90
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
Westminster Commons was found in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.
Report Facts
Stories: 2
Construction Type: 1
Construction Year: 1965
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 22, 2025
Visit Reason
A State Licensure survey was conducted at Westminster Commons from May 19, 2025 through May 22, 2025 to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey identified multiple deficiencies including incomplete care plans for residents with specific medical needs, improper positioning of urinary catheter bags, inaccurate documentation of abuse incidents, and lack of assessment and consent for side rail use. These deficiencies posed risks for unmet care needs, infection, incomplete records, and resident safety.
Deficiencies (4)
Failure to ensure care plans were comprehensively developed for two residents, including lack of care plan focus for G-tube care and psychotropic medication monitoring.
Failure to ensure urinary catheter bags were properly positioned, with catheter bag observed resting uncovered on the floor.
Failure to ensure accurate documentation of verbal and physical abuse incidents in resident records, with incidents documented only in one resident's record but not the other involved resident's record.
Failure to assess resident for entrapment risk, obtain informed consent, and obtain physician's order for side rail use for one resident with side rails in place.
Report Facts
Sample size: 46
Residents with care plan deficiencies: 2
Residents reviewed for urinary catheters: 3
Residents with catheter bag deficiency: 1
Residents reviewed for abuse documentation: 9
Residents with abuse documentation deficiency: 1
Residents reviewed for side rails: 46
Residents with side rail deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 9 | Administered medication via G-tube to Resident R18 | |
| MDS Coordinator (MDSC) | Confirmed lack of care plans for G-tube and psychotropic medication for residents R18 and R52 | |
| Director of Nursing (DON) | Confirmed care plan requirements for G-tube and psychotropic medication, and side rail assessments | |
| Licensed Practical Nurse (LPN) 2 and LPN 3 | Confirmed catheter bags should be kept off the floor and observed deficiency with Resident R10 | |
| Regional Director of Clinical Operations (RDCO) | Expected urinary catheter bags to be hung off the floor and confirmed documentation failure for abuse incident | |
| Certified Nursing Assistant (CNA) 15 | Reported Resident R20 used side rails to assist herself and staff | |
| Unit Manager Licensed Practical Nurse (LPN) 3 | Confirmed side rail assessment, consent, and physician order requirements and verified deficiencies for Resident R20 | |
| Administrator | Confirmed lack of abuse incident documentation in Resident R189's record |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 17
Date: May 22, 2025
Visit Reason
A recertification survey was conducted at Westminster Commons from May 19, 2025, through May 22, 2025, including investigation of multiple complaint intake numbers.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey, including allegations of neglect, abuse, and improper care.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to treat residents with respect and dignity, failure to ensure risk versus benefits were provided for unnecessary medications, failure to ensure call light accessibility, inaccurate code status documentation, failure to prevent abuse and neglect, failure to monitor psychotropic medication side effects, failure to ensure timely medication administration, incomplete discharge summaries, inaccurate MDS assessments, incomplete care plans, improper catheter bag positioning, and failure to assess and document side rail use.
Deficiencies (17)
Failure to treat residents with respect and dignity, including staff yelling and swearing in front of residents and not honoring medication administration preferences.
Failure to ensure risk versus benefits were provided to resident or representative for unnecessary medications.
Failure to ensure residents' call light was within reach, placing resident at risk of inability to call for assistance.
Failure to ensure primary system for identifying resident's code status accurately reflected end of life wishes.
Failure to ensure residents were free from abuse, including substantiated neglect and resident-to-resident verbal and physical abuse.
Failure to ensure monitoring of psychotropic medication side effects was conducted.
Failure to ensure all allegations of abuse and neglect were reported immediately but not later than two hours after the allegation.
Failure to conduct thorough investigations for incidents of potential abuse.
Failure to ensure a complete discharge summary was provided to resident or representative.
Failure to ensure Minimum Data Set (MDS) assessments were accurate regarding hospice care and feeding tube.
Failure to ensure care plans were comprehensively developed for residents with gastrostomy tubes and psychotropic medications.
Failure to ensure timely medication administration and adherence to physician orders for G-Tube medication administration.
Failure to ensure residents received proper treatment and services to maintain vision and hearing abilities.
Failure to ensure urinary catheter bags were properly positioned to prevent contamination and infection.
Failure to assess, evaluate, inform, and obtain physician order and consent for side rail use.
Failure to post current and accurate nurse staffing information including date and actual hours worked.
Failure to ensure accurate documentation of abuse incidents in resident records.
Report Facts
Resident census: 83
Deficiencies cited: 15
Medication administration times: 15
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Involved in yelling/swearing incident and medication administration |
| RN2 | Registered Nurse | Involved in staff conflict and neglect incident |
| DON | Director of Nursing | Provided multiple interviews regarding facility policies and incidents |
| Administrator | Facility Administrator | Provided interviews regarding incident investigations and reporting |
| CMAT1 | Certified Medication Aide Tech | Administered medications orally instead of via G-Tube |
| SSD | Social Services Director | Discussed code status and discharge summary processes |
| RN4 | Registered Nurse | Involved in yelling/swearing incident |
| LPN6 | Licensed Practical Nurse | Involved in staff conflict |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 18
Date: May 22, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations related to resident rights, care, medication administration, abuse prevention, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, improper medication administration, incomplete and inaccurate assessments and care plans, failure to timely report and investigate abuse and neglect allegations, improper catheter care, failure to post accurate nurse staffing information, and failure to maintain complete and accurate resident records.
Deficiencies (18)
Failed to ensure residents were treated with respect and dignity; staff engaged in yelling and swearing in front of residents.
Failed to ensure a resident needing assistance with meals was assisted by staff sitting down.
Failed to ensure a resident had their choice honored to receive medications by gastrostomy tube.
Failed to ensure risk versus benefits were provided to the resident or representative for unnecessary medications.
Failed to ensure residents' call light was within reach for a resident with severe physical limitations.
Failed to ensure primary system for identifying resident's code status accurately reflected end of life wishes.
Failed to ensure residents were free from abuse; substantiated neglect by CNA for not turning resident timely; verbal and physical abuse incidents not fully investigated or reported timely.
Failed to ensure monitoring of psychotropic medication side effects was conducted.
Failed to ensure all allegations of abuse and neglect were reported immediately but not later than two hours after the allegation.
Failed to ensure complete investigations for incidents of potential abuse.
Failed to ensure a complete discharge summary was provided to the resident or representative.
Failed to ensure Minimum Data Set (MDS) assessments were accurate regarding hospice care and feeding tube.
Failed to ensure timely medication administration and adherence to physician orders for medication administration via gastrostomy tube.
Failed to ensure residents received proper treatment and services to maintain vision and hearing abilities.
Failed to ensure residents with urinary catheter bags were properly positioned to prevent contamination and potential urinary tract infections.
Failed to assess, evaluate, obtain consent, and physician's order for use of bed rails for a resident with side rails.
Failed to post completed up-to-date and current nurse staffing information including date and actual hours worked.
Failed to ensure residents reviewed for verbal and physical abuse had accurate documentation of abuse incidents in the resident record.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Admitted unprofessional behavior and yelling in front of residents |
| RN4 | Registered Nurse | Involved in yelling incident with LPN1 in front of residents |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding staff behavior, expectations, and investigations |
| RN2 | Registered Nurse | Reported feeling threatened by LPN6 during an argument |
| LPN6 | Licensed Practical Nurse | Involved in argument with RN2, suspended and no longer employed |
| CMAT1 | Certified Medication Aide Tech | Fed resident while standing, not following proper feeding protocol |
| LPN2 | Licensed Practical Nurse | Observed improper feeding assistance by CMAT1 |
| LPN4 | Licensed Practical Nurse | Confirmed resident could use call light if positioned properly |
| RN3 | Registered Nurse | Confirmed resident could use call light if positioned properly |
| LPN3 | Licensed Practical Nurse | Confirmed resident could use call light if positioned properly |
| CNA48 | Certified Nursing Assistant | Substantiated neglect for not turning resident timely |
| RN1 | Registered Nurse | Reported resident's aggressive behavior prior to incident |
| CNA16 | Certified Nursing Assistant | Witnessed resident with hand in roommate's underwear |
| Administrator | Facility Administrator | Provided multiple interviews regarding abuse investigations and reporting |
| Regional Director of Clinical Operations | Regional Director of Clinical Operations | Provided interviews regarding abuse investigations and reporting |
| Social Services Director | Social Services Director | Provided interviews regarding discharge summary and ancillary services |
| CMAT2 | Certified Medication Aide Tech | Confirmed resident could use call light if positioned properly |
| LPN7 | Licensed Practical Nurse | Confirmed resident could use call light if positioned properly |
| LPN5 | Licensed Practical Nurse | Identified as administering medications late |
| LPN8 | Licensed Practical Nurse | Identified as administering medications late |
| CNA9 | Certified Nursing Assistant | Confirmed resident was hard of hearing and had hearing aid that did not work |
| LPN9 | Licensed Practical Nurse | Administered medication via G-tube |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 15
Date: May 22, 2025
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with regulatory requirements, including resident rights, medication administration, abuse prevention, care planning, and other aspects of care.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to ensure timely medication administration, failure to follow physician orders for medication administration via G-Tube, failure to ensure proper reporting and investigation of abuse and neglect allegations, failure to maintain accurate and complete medical records, failure to post current nurse staffing information, failure to provide complete discharge summaries, failure to ensure accurate MDS assessments, failure to develop comprehensive care plans, failure to maintain proper catheter care, failure to assist residents with hearing needs, and failure to properly assess and document side rail use.
Deficiencies (15)
Failed to ensure residents were treated with respect and dignity; staff yelling and swearing in front of residents.
Failed to ensure risk versus benefits were provided for unnecessary medications for one resident.
Failed to ensure residents' call light was within reach for one resident with severe physical limitations.
Failed to ensure primary system for identifying resident's code status accurately reflected end of life wishes for two residents.
Failed to ensure four residents were free from abuse; substantiated neglect and verbal abuse incidents.
Failed to timely report suspected abuse and neglect for two residents.
Failed to conduct thorough investigations for incidents of potential abuse for three residents.
Failed to ensure complete discharge summary was provided to resident and/or representative for one resident.
Failed to ensure Minimum Data Set (MDS) assessments were accurate for two residents regarding hospice care and feeding tube.
Failed to ensure timely medication administration and adherence to physician orders for medication administration via G-Tube for two residents.
Failed to ensure residents received proper treatment and services to maintain vision and hearing abilities for one resident.
Failed to ensure residents with urinary catheter bags were properly positioned to prevent infection for one resident.
Failed to assess, evaluate, inform, and obtain physician's order and consent for side rail use for one resident.
Failed to post completed up-to-date nurse staffing information including current date and actual hours worked for licensed and unlicensed staff.
Failed to ensure accurate documentation of abuse incidents in resident record for one resident.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 83
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Admitted unprofessional behavior and yelling in front of residents |
| RN4 | Registered Nurse | Involved in yelling incident with LPN1 in front of residents |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding staff behavior, abuse investigations, and care expectations |
| RN2 | Registered Nurse | Involved in altercation with LPN6 and neglect incident with R136 |
| LPN6 | Licensed Practical Nurse | Involved in altercation with RN2 |
| CMAT1 | Certified Medication Aide Tech | Administered medications by mouth instead of G-Tube for R18 |
| LPN2 | Licensed Practical Nurse | Confirmed CMAT1 did not follow physician orders for G-Tube medication administration |
| LPN3 | Licensed Practical Nurse | Discussed process for updating resident code status and failure to delete old orders |
| CNA48 | Certified Nursing Assistant | Substantiated neglect for not turning resident R136 timely |
| RN1 | Registered Nurse | Reported behavior of resident R17 prior to incident |
| CNA16 | Certified Nursing Assistant | Witnessed inappropriate behavior of resident R17 |
| Administrator | Administrator | Provided multiple interviews regarding abuse reporting and investigations |
| Regional Director of Clinical Operations | Regional Director of Clinical Operations | Provided interviews regarding abuse investigations and reporting |
| Social Services Director | Social Services Director | Discussed discharge summary and ancillary services |
| LPN9 | Licensed Practical Nurse | Administered medication via G-Tube for R18 |
| CNA9 | Certified Nursing Assistant | Observed resident R22's hearing device status |
| LPN15 | Certified Nursing Assistant | Reported resident R20 used side rails for assistance |
| LPN2 | Licensed Practical Nurse | Observed catheter bag positioning for R10 |
Inspection Report
Abbreviated Survey
Census: 84
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00251397 and GA00251418.
Complaint Details
Complaint GA00251397 was unsubstantiated; complaint GA00251418 was substantiated with no deficiencies cited.
Findings
Complaint GA00251397 was unsubstantiated, and complaint GA00251418 was substantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 22, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Westminster Commons, indicating regulatory oversight and corrective actions following an inspection.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings within the provided page.
Inspection Report
Re-Inspection
Census: 82
Deficiencies: 0
Date: Oct 22, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a Complaint Survey on September 5, 2024.
Complaint Details
The revisit survey was conducted following a Complaint Survey on September 5, 2024. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the September 5, 2024 Complaint Survey were found to be corrected during the revisit survey.
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
A State Licensure survey was conducted at Westminster Commons from August 28, 2024, through September 5, 2024, to assess compliance with state health regulations.
Findings
The survey revealed that there were no State Health deficiencies cited during the inspection period.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 1
Date: Sep 5, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted at Westminster Commons to investigate multiple complaints (GA00244077, GA00244149, GA00245233, GA00246004, and GA00246649) initiated on 2024-08-28 and concluded on 2024-09-05.
Complaint Details
Complaint numbers GA00244077, GA00244149, GA00246004, and GA00246649 were unsubstantiated. One of two allegations from Complaint GA00245233 was substantiated with a deficiency related to fall prevention.
Findings
The facility failed to adequately supervise and implement fall prevention interventions for one resident (R2) after multiple documented falls. Specifically, there was no documented evidence of post-fall assessments, care plans, or interventions following several fall incidents, and a Patient at Risk meeting was not held as required.
Deficiencies (1)
Failure to adequately supervise, evaluate, and implement fall prevention interventions for resident R2 after multiple falls.
Report Facts
Facility census: 82
Complaints investigated: 5
Falls documented for resident R2: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 2024-09-04 confirming lack of Patient at Risk meeting and delayed care plan for falls for resident R2 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 5, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to adequately supervise and implement fall prevention interventions for a resident who experienced multiple falls.
Complaint Details
The complaint investigation revealed that the facility did not conduct post-fall assessments or update care plans after multiple falls of resident R2. The Director of Nursing confirmed no Patient at Risk meeting occurred after the falls and that the care plan for falls was only created after the third fall within two months.
Findings
The facility failed to ensure fall interventions were implemented for one resident after multiple documented falls. There was no documented evidence of post-fall assessments, care plans, or interventions following several fall incidents, and no Patient at Risk meeting was held as required.
Deficiencies (1)
Failure to adequately supervise, evaluate, and implement fall prevention interventions for a resident after multiple falls.
Report Facts
Number of documented falls for resident R2: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed lack of post-fall assessments, Patient at Risk meeting, and delayed care plan implementation for resident R2. |
Inspection Report
Abbreviated Survey
Census: 80
Deficiencies: 0
Date: May 29, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00247037.
Complaint Details
Complaint #GA00247037 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Westminster Commons, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 79
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
A revisit survey was conducted on 3/13/2024 and 3/14/2024 to verify correction of deficiencies cited during the 1/19/2024 Recertification Survey conducted in conjunction with a Complaint Survey.
Findings
All deficiencies cited as a result of the 1/19/2024 Recertification Survey and Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 11, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Deficiencies: 1
Date: Feb 6, 2024
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 01/29/2024 and 02/04/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 01/22/2024 and 01/28/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Life Safety
Census: 78
Capacity: 90
Deficiencies: 2
Date: Jan 23, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically failing to maintain regular fire alarm system testing and maintenance, and failing to assure corridor doors resisted smoke passage due to small penetrations at door knobs in resident rooms.
Deficiencies (2)
Failure to maintain regular fire alarm system testing and maintenance; no recent smoke detector sensitivity testing in the last 24 months with no records available.
Failure to assure corridor doors resist the passage of smoke; resident room doors had small penetrations at door knobs.
Report Facts
Smoke Compartments affected: 1
Stories: 2
Construction Type: 332
Certified beds: 90
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 01/15/2024 and 01/21/2024 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jan 19, 2024
Visit Reason
A State Licensure survey was conducted at Westminster Commons from January 15, 2024 through January 19, 2024 to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey revealed multiple deficiencies including failure to notify the State Long-Term Care Ombudsman of hospital transfers, failure to develop comprehensive person-centered care plans for residents, improper medication storage and administration, expired medications not discarded, medication error rate exceeding acceptable limits, and failure to document consent or refusal for pneumonia vaccinations for several residents.
Deficiencies (7)
Failure to notify the State Long-Term Care Ombudsman of hospital transfers for one resident.
Failure to develop a comprehensive person-centered care plan for two residents.
Failure to store physician ordered medications in a locked compartment for one resident.
Failure to discard medications not administered for one resident.
Failure to discard expired medications located in the refrigerator on the Memory Care Unit.
Medication error rate of 27.59% due to eight errors out of 29 opportunities for two residents.
Failure to document consent or refusal for pneumonia vaccinations for three residents.
Report Facts
Medication error rate: 27.59
Sample residents reviewed: 22
Residents with missing pneumonia vaccination documentation: 3
Residents with medication care plan deficiencies: 2
Expired vaccine boxes found: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN4 | Licensed Practical Nurse | Involved in medication administration errors including crushing medications and administering blood pressure meds against parameters |
| LPN7 | Licensed Practical Nurse | Left medications unattended on medication cart |
| CMAT1 | Certified Medication Aide Tech | Failed to discard medications and left medications in medicine cup for resident who was asleep |
| Director of Nursing | Director of Nursing | Provided statements confirming medication and notification deficiencies |
| MDS Coordinator | MDS Coordinator | Confirmed residents lacked comprehensive care plans |
| Social Services Director | Social Services Director | Stated she did not send monthly list to Ombudsman as instructed not to |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed lack of documentation for pneumonia vaccination consent or refusal |
Inspection Report
Routine
Census: 75
Deficiencies: 13
Date: Jan 19, 2024
Visit Reason
A standard survey was conducted at Westminster Commons from January 15, 2024 through January 19, 2024, including investigation of multiple complaint intake numbers which were found to be unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00241382, GA00239275, GA00239870, GA00234006, and GA00233353 were investigated in conjunction with the standard survey and were found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to prevent resident-to-resident abuse, failure to report and investigate alleged abuse, failure to notify the Ombudsman of hospital transfers, incomplete care plans, medication administration errors, lack of communication with dialysis center, missing pharmacist medication regimen reviews, medication storage issues, incomplete hospice communication, and failure to offer or document pneumococcal vaccinations.
Deficiencies (13)
Failed to prevent resident to resident abuse resulting in minor injuries to residents.
Failed to report an allegation of abuse to the state agency for one resident.
Failed to thoroughly investigate an allegation of abuse for one resident.
Failed to notify the State Long-Term Care Ombudsman of hospital transfers for one resident.
Failed to develop a comprehensive person-centered care plan for two residents.
Failed to review and revise care plan interventions for one resident after significant change.
Failed to administer a physician ordered antibiotic medication for one resident.
Medication error rate exceeded 5% for two residents with eight errors out of 29 opportunities.
Failed to have ongoing communication and collaboration with dialysis center for one resident.
Failed to ensure monthly review of drug regimens by licensed pharmacist for two residents.
Failed to store physician ordered medications in locked compartment, failed to discard medications not administered, and failed to discard expired medications.
Failed to implement communication process and documentation between facility and hospice provider for one resident.
Failed to offer or document consent/refusal for pneumococcal vaccinations for three residents.
Report Facts
Census: 75
Medication error rate: 27.59
Medication not administered: 4
Pneumococcal vaccination doses missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in medication error finding and abuse prevention interventions |
| LPN4 | Licensed Practical Nurse | Named in medication administration errors |
| LPN7 | Licensed Practical Nurse | Named in medication storage deficiency |
| DON | Director of Nursing | Named in multiple findings including abuse prevention, medication errors, and hospice communication |
| ADON | Assistant Director of Nursing | Named in pneumococcal vaccination deficiency |
| MDS Coordinator | Named in care plan deficiencies | |
| CMAT1 | Certified Medication Aide Tech | Named in medication storage deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Jan 19, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse, failure to report and investigate abuse allegations, failure to notify ombudsman of hospital transfers, incomplete care plans, medication administration errors, and other regulatory concerns at Westminster Commons nursing home.
Complaint Details
The complaint investigation was substantiated for multiple incidents of resident-to-resident abuse, failure to report and investigate abuse allegations, failure to notify ombudsman of hospital transfers, medication errors, and other regulatory violations.
Findings
The facility failed to prevent resident-to-resident abuse resulting in minor injuries, failed to timely report and thoroughly investigate abuse allegations, failed to notify the ombudsman of hospital transfers, failed to develop and update comprehensive care plans, failed to administer medications as ordered, failed to maintain communication with dialysis center, failed to ensure monthly pharmacist drug regimen reviews, had a medication error rate above 5%, failed to properly store and discard medications, and failed to provide or document pneumonia vaccinations for some residents.
Deficiencies (13)
Failed to prevent resident-to-resident abuse resulting in minor injuries to residents.
Failed to timely report suspected abuse to the state agency for one resident.
Failed to thoroughly investigate an allegation of abuse for one resident.
Failed to notify the State Long-Term Care Ombudsman of hospital transfers for one resident.
Failed to develop a comprehensive person-centered care plan for two residents.
Failed to review and revise care plan interventions after significant change for one resident.
Failed to administer a physician ordered antibiotic medication as prescribed for one resident.
Failed to have ongoing communication and collaboration with dialysis center for one resident receiving dialysis.
Failed to ensure monthly drug regimen reviews were completed by a licensed pharmacist for two residents.
Medication error rate exceeded 5% due to errors in administration for two residents.
Failed to store medications in locked compartments, failed to discard unadministered and expired medications.
Failed to implement communication process and documentation between facility and hospice provider for one resident.
Failed to offer or document consent/refusal for pneumonia vaccinations for three residents.
Report Facts
Residents sample size: 22
Medication error rate: 27.59
Medication administration dates missed: 4
Expired vaccine boxes: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Interviewed regarding resident aggressive behavior and hospice communication |
| LPN4 | Licensed Practical Nurse | Observed administering medications with errors for residents R41 and R235 |
| LPN7 | Licensed Practical Nurse | Observed leaving medications unsecured on medication cart for resident R234 |
| CMAT1 | Certified Medication Aide Tech | Interviewed regarding unadministered medications and expired vaccines |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication errors, abuse investigations, and hospice communication |
| ADON | Assistant Director of Nursing | Interviewed regarding pneumonia vaccination documentation |
| MDSC | MDS Coordinator | Interviewed regarding care plan deficiencies for residents R27 and R29 |
Inspection Report
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
The inspection was conducted to review the facility's reporting compliance with COVID-19 data to the CDC's National Healthcare Safety Network during a required seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 01/01/2024 and 01/07/2024 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jan 2, 2024
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 12/25/2023 and 12/31/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Routine
Deficiencies: 1
Date: Dec 26, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with reporting requirements related to COVID-19 data submission to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN during a seven-day period from 12/18/2023 to 12/24/2023 as required by regulation, potentially causing more than minimal harm to residents.
Deficiencies (1)
Failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Oct 17, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 10/10/2022 and 10/16/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Date range: Between 10/10/2022 and 10/16/2022
Inspection Report
Deficiencies: 1
Date: Sep 19, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 09/12/2022 and 09/18/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Sep 12, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period from 09/05/2022 to 09/11/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Sep 6, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 08/29/2022 and 09/04/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Aug 22, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/15/2022 to 08/21/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 18, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Westminster Commons, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 0
Date: Aug 17, 2022
Visit Reason
A revisit survey was conducted on 8/17/22 to verify correction of deficiencies cited during the 6/3/22 recertification survey.
Findings
All deficiencies cited as a result of the 6/3/22 recertification survey were found to be corrected.
Report Facts
Census: 72
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 17, 2022
Visit Reason
A revisit survey was conducted on 8/17/22 in conjunction with investigation of Complaint intake Number GA00225816.
Complaint Details
Complaint intake Number GA00225816 was investigated and found to be unsubstantiated with no deficiencies.
Findings
All deficiencies cited as a result of the 6/3/22 recertification survey were found to be corrected. The complaint investigation found the complaint was unsubstantiated with no deficiencies.
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 16, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/08/2022 to 08/14/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Aug 8, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/01/2022 to 08/07/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 07/25/2022 and 07/31/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jul 25, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 07/18/2022 and 07/24/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 3, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from 5/31/22 through 6/3/22 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the licensure survey.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 4
Date: Jun 3, 2022
Visit Reason
The inspection was conducted based on complaints regarding failure to accurately document wound care, maintain an effective infection prevention and control program, implement an antibiotic stewardship program, and perform COVID-19 testing on residents and staff.
Complaint Details
The visit was complaint-related due to allegations of inadequate wound care documentation, ineffective infection prevention and control program, lack of antibiotic stewardship, and failure to perform and document COVID-19 testing as required.
Findings
The facility failed to ensure licensed nursing staff accurately documented daily wound care for two residents, maintain an effective infection prevention and control program with proper documentation and surveillance data, implement an antibiotic stewardship program with monitoring protocols, and produce evidence of COVID-19 testing logs or line listings for residents and staff. The facility census was 72 residents.
Deficiencies (4)
Failure to ensure licensed nursing staff accurately documented daily wound care for two residents reviewed for pressure related wounds.
Failure to maintain an effective infection prevention and control program with ongoing surveillance, recognition, investigation, and control of infection.
Failure to implement an antibiotic stewardship program to monitor antibiotic use.
Failure to produce evidence of COVID-19 testing of residents and staff, including lack of testing logs or line listing forms.
Report Facts
Residents affected: 2
Facility census: 72
Residents affected: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) Wound Care Nurse | Interviewed regarding wound care documentation and treatment responsibilities | |
| Administrator | Interviewed regarding wound care nurse staffing, infection control program, antibiotic stewardship, and COVID-19 testing documentation | |
| Treatment Nurse | Interviewed regarding wound care treatments and weekend coverage | |
| Director of Nursing (DON) | Responsible for infection prevention program and antibiotic stewardship; absent during survey and removed infection control materials from facility | |
| Regional Nurse Consultant | Interviewed regarding facility's inability to produce testing logs or line listings |
Inspection Report
Life Safety
Census: 70
Capacity: 90
Deficiencies: 0
Date: May 31, 2022
Visit Reason
A Life Safety Survey was conducted to review the facility's compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
Westminister Commons was found in substantial compliance with the requirements for participation in Medicare/Medicaid and the related Life Safety Code standards.
Report Facts
Certified Beds: 90
Census: 70
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Date: Mar 9, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating complaint #GA00212715.
Complaint Details
Complaint #GA00212715 was substantiated with no regulatory violations.
Findings
The complaint was substantiated with no regulatory violations. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 4, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints identified by their numbers.
Complaint Details
Complaints #GA00211821, #GA00208143, #GA00206292, #GA00206103, #GA00204859, #GA00203685, #GA00205795, and #GA00211819 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 61
Deficiencies: 0
Date: Dec 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 0
Date: Aug 10, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 3/11/2020 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 3/11/2020; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 3/11/2020 Complaint Survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 0
Date: Aug 10, 2020
Visit Reason
A revisit survey was conducted on 08/10/2020 to verify correction of deficiencies cited during the 03/11/2020 complaint survey.
Complaint Details
The revisit survey was conducted following a complaint survey on 03/11/2020; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 03/11/2020 complaint survey were found to be corrected during this revisit survey.
Report Facts
Census: 72
Inspection Report
Routine
Census: 72
Deficiencies: 0
Date: Jun 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices for COVID-19.
Report Facts
Total census: 72
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 3
Date: Mar 11, 2020
Visit Reason
A Partial/Extended Survey was conducted to investigate complaint intake number GA00203599 from 3/2/2020 to 3/11/2020. The complaint investigation was substantiated with deficiencies cited, including Substandard Quality of Care.
Complaint Details
Complaint intake number GA00203599 was investigated and substantiated with cited deficiencies including Substandard Quality of Care.
Findings
The facility failed to ensure the medication supply room was locked and accessible only to authorized staff, and failed to store potentially hazardous chemicals securely on a housekeeping cart and in the laundry room on the memory care unit. These deficiencies had the potential to affect 69 ambulatory and/or memory impaired residents. The facility implemented corrective actions including staff in-services, locking mechanisms, signage, and monitoring tools.
Deficiencies (3)
Medication supply room was unlocked and accessible to residents and visitors.
Potentially hazardous chemicals were stored on an unattended housekeeping cart and in an unlocked laundry room closet accessible to cognitively impaired residents.
Laundry room door was propped open and unlocked, allowing resident access to hazardous chemicals.
Report Facts
Census: 77
Potentially affected residents: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor EE | Housekeeping Supervisor | Responsible for leaving housekeeping cart unattended; provided training and in-services on cleaning and chemical safety. |
| Director of Nursing | Director of Nursing (DON) | Verified medication supply room was unlocked; described key control and staff in-services. |
| Licensed Practical Nurse AA | Licensed Practical Nurse (LPN) | Reported on housekeeping cart and housekeeping staff practices. |
| Laundry Aide CC | Laundry Aide | Observed resident entering laundry room; described laundry room door being propped open. |
| Laundry Aide DD | Laundry Aide | Described laundry room door being propped open with garbage bag. |
| Certified Nursing Assistant BB | Certified Nursing Assistant (CNA) | Central Supply personnel; stated medication supply room is normally locked. |
| Housekeeper II | Housekeeper | Described keeping chemicals locked on cleaning cart and receiving training. |
| Licensed Practical Nurse GG | Licensed Practical Nurse (LPN) | Reported laundry room door often left open for staff access. |
| Interim Administrator HH | Interim Administrator | Reported staff concerns; described corrective actions and QAPI involvement. |
| Administrator | Administrator | Reported awareness of unlocked doors and housekeeping cart issues; described corrective actions and QAPI involvement. |
Inspection Report
Deficiencies: 0
Date: Mar 5, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Westminster Commons, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 77
Deficiencies: 0
Date: Mar 5, 2020
Visit Reason
A revisit survey was conducted from 2020-03-02 through 2020-03-03 to verify correction of deficiencies found in the prior 2020-01-09 survey.
Findings
All deficiencies identified in the 2020-01-09 survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 2, 2020
Visit Reason
The inspection was conducted as a complaint survey to investigate concerns about unlocked medication supply and laundry rooms, and unattended housekeeping carts with accessible hazardous chemicals.
Complaint Details
The deficiencies were identified during a complaint survey triggered by concerns about unlocked medication and supply rooms and unattended housekeeping carts with accessible chemicals.
Findings
The facility failed to ensure the medication supply room was locked, allowing access to residents and visitors. Hazardous chemicals were found accessible on an unattended housekeeping cart and in the laundry room on the memory care unit. The facility initiated corrective actions including staff in-services, changing locks, and monitoring to ensure compliance.
Deficiencies (3)
Medication supply room was unlocked and accessible to residents and visitors.
Housekeeping cart on memory care unit had hazardous chemicals accessible to cognitively impaired residents.
Laundry room door was left open and unlocked, with chemicals accessible to residents.
Report Facts
Potentially affected residents: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor EE | Housekeeping Supervisor | Responsible for leaving the housekeeping cart unattended; provided training and in-services on cleaning and chemical safety. |
| Licensed Practical Nurse AA | Licensed Practical Nurse | Interviewed regarding unattended housekeeping cart and lack of knowledge on how to handle it. |
| Certified Nursing Assistant BB | Central Supply Personnel | Confirmed medication supply room is normally locked and was left unlocked for one minute. |
| Laundry Aide CC | Laundry Aide | Observed resident entering laundry room and explained door kept open due to heat and fumes. |
| Laundry Aide DD | Laundry Aide | Described method of keeping laundry room door propped open. |
| Interim Administrator HH | Interim Administrator | Communicated concerns to staff and initiated corrective actions including in-services and lock changes. |
| Housekeeper II | Housekeeper | Reported keeping chemicals locked on cleaning cart and receiving training from Housekeeping Supervisor EE. |
| Director of Nursing | Director of Nursing | Verified unlocked medication supply room and described staff training on hazardous chemicals. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 3
Date: Jan 9, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00201842, GA00201066, and GA00200709, with substantiation of federal violations related to complaint GA00201066.
Complaint Details
The investigation was initiated due to complaints GA00201842, GA00201066, and GA00200709. GA00201066 was substantiated with federal violations cited.
Findings
The facility failed to ensure controlled medications were free from misappropriation for five residents, with missing controlled drug records and unaccounted medications. Additionally, the facility failed to provide complete and accurate documentation on Medication Administration Records (MARs) related to administration of PRN opioid pain medications for five residents. The Consultant Pharmacist failed to audit MARs and Controlled Drug Records adequately to identify documentation irregularities.
Deficiencies (3)
Failure to ensure controlled medications were free from misappropriation for five residents, with missing controlled drug records and unaccounted medications.
Failure to provide complete and accurate documentation on Medication Administration Records related to PRN opioid pain medication administration for five residents.
Failure to maintain complete, accurate, and accessible medical records, including documentation of PRN medication administration and pain assessments.
Report Facts
Facility census: 71
Missing controlled drug administrations: 74
Missing controlled drug administrations: 82
Missing controlled drug administrations: 88
Missing controlled drug administrations: 15
Missing controlled drug administrations: 4
Missing controlled drug administrations: 15
Missing controlled drug administrations: 31
Missing controlled drug administrations: 39
Missing controlled drug administrations: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Suspected by staff and terminated for involvement in controlled drug discrepancies |
| LPN CC | Licensed Practical Nurse | Reported noticing controlled medication discrepancies |
| LPN DD | Licensed Practical Nurse | Reported noticing controlled medication discrepancies and described pain assessment and documentation practices |
| LPN EE | Licensed Practical Nurse | Former charge nurse who described pain assessment and documentation practices |
| LPN FF | Licensed Practical Nurse | Described usual documentation practices for PRN medications |
| Director of Nurses | Director of Nursing | Interviewed multiple times regarding missing controlled drug records, audits, and education provided |
| Consultant Pharmacist | Consultant Pharmacist | Responsible for monthly medication reviews but failed to identify documentation irregularities |
| Pharmacy Nurse Consultant Manager | Pharmacy Nurse Consultant Manager | Confirmed audit findings of missing medication documentation |
| Administrator | Facility Administrator | Interviewed regarding expectations for medication documentation and response to discrepancies |
Inspection Report
Abbreviated Survey
Census: 71
Deficiencies: 1
Date: Jan 9, 2020
Visit Reason
An Abbreviated/Partial Extended licensure survey was conducted to investigate complaint numbers GA00201842, GA00201066, and GA00200709.
Complaint Details
The survey investigated complaints GA00201842, GA00201066, and GA00200709.
Findings
The Consultant Pharmacist and the facility failed to audit Medication Administration Records (MARs) and Controlled Drug Records to address documentation irregularities related to the administration of as needed (PRN) controlled medications for two residents. Multiple discrepancies were found between MARs and Controlled Drug Records for PRN Oxycodone administrations, with missing documentation of pain assessments and medication effectiveness.
Deficiencies (1)
Failure to audit Medication Administration Records and Controlled Drug Records to address documentation irregularities related to PRN controlled medications for two residents.
Report Facts
Facility census: 71
PRN Oxycodone 15 mg administrations documented on MAR: 44
PRN Oxycodone 15 mg administrations documented on Controlled Drug Record: 96
PRN Oxycodone 20 mg administrations documented on MAR: 33
PRN Oxycodone 20 mg administrations documented on Controlled Drug Record: 115
PRN Oxycodone 20 mg administrations documented on MAR: 52
PRN Oxycodone 20 mg administrations documented on Controlled Drug Record: 140
PRN Oxycodone 20 mg administrations documented on MAR: 15
PRN Oxycodone 20 mg administrations documented on Controlled Drug Record: 30
PRN Oxycodone 10 mg administrations documented on MAR: 17
PRN Oxycodone 10 mg administrations documented on Controlled Drug Record: 48
PRN Oxycodone 10 mg administrations documented on MAR: 36
PRN Oxycodone 10 mg administrations documented on Controlled Drug Record: 75
PRN Oxycodone 10 mg administrations documented on MAR: 7
PRN Oxycodone 10 mg administrations documented on Controlled Drug Record: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding missing Controlled Drug Records and documentation irregularities |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed about monthly medication reviews and auditing practices |
| Administrator | Administrator | Interviewed about expectations for Consultant Pharmacist's review of Controlled Drug Records and MARs |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 17, 2019
Visit Reason
A complaint survey was conducted to investigate complaints GA00196123 and GA00195816 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to complaints GA00196123 and GA00195816; no deficiencies were found.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 6, 2019
Visit Reason
A follow-up survey was conducted to verify that all previously cited deficiencies had been corrected.
Findings
The follow-up survey noted that all previously cited tags had been corrected.
Inspection Report
Re-Inspection
Census: 74
Deficiencies: 0
Date: Jan 15, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the extended recertification survey conducted in November 2018.
Findings
All deficiencies cited in the prior extended recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Census: 81
Deficiencies: 1
Date: Jan 3, 2019
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
The facility failed to maintain the generator by not installing a remote annunciator by the plan of correction date, which could place 81 residents at risk in the event of an emergency with backup power malfunction.
Deficiencies (1)
Failure to install a remote annunciator for the generator as required by NFPA 99 Chapter 6 Section 6.4.1.1.17.
Report Facts
Residents at risk: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M accompanied the tour and confirmed findings |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 27, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint numbers GA00193197 and GA00193494.
Complaint Details
Complaint numbers GA00193197 and GA00193494 were investigated and found to be unsubstantiated.
Findings
The complaints GA00193197 and GA00193494 were investigated and found to be unsubstantiated.
Inspection Report
Enforcement
Census: 78
Deficiencies: 6
Date: Nov 28, 2018
Visit Reason
The visit was conducted due to an Immediate Jeopardy identified during an extended recertification survey related to failure to follow advance directives and failure to notify physician of resident change in condition, resulting in serious injury or death.
Findings
The facility failed to ensure that CPR was not initiated on a resident with a Do Not Resuscitate (DNR) order, failed to follow up on advance directives for several residents, failed to timely notify the physician of a resident's change in condition, and failed to effectively monitor and implement quality assurance processes related to these issues. Immediate Jeopardy was identified and later removed after corrective actions were implemented.
Deficiencies (6)
Failure to follow advance directives and initiate CPR on a resident with a DNR order.
Failure to develop and implement comprehensive care plans consistent with resident rights and preferences.
Failure to provide services meeting professional standards, including verifying advance directives and following CPR policies.
Failure to provide basic life support consistent with physician orders and resident advance directives.
Failure of administration to ensure effective monitoring of advance directive system, staff training, and quality assurance processes.
Failure of quality assurance committee to develop and implement appropriate plans of action to correct identified quality deficiencies.
Report Facts
Residents with DNR: 8
Residents in facility: 78
Staff CPR certification: 47
Staff CPR certification: 56
Residents without code status documented: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in relation to initiating CPR on resident with DNR and verifying code status |
| LPN BB | Licensed Practical Nurse | Named in relation to initiating CPR on resident with DNR |
| CNA CC | Certified Nursing Assistant | Named in relation to discovering resident with change in condition and initiating response |
| RN NN | Registered Nurse | Named in relation to care of resident during code blue and CPR initiation |
| Administrator | Facility Administrator | Named in relation to oversight and responsibility for quality assurance and staff training |
| DON | Director of Nursing | Named in relation to oversight of nursing staff, audits, and corrective actions |
| Social Worker | Social Services Director | Named in relation to follow-up on advance directives and audits |
| VP of Clinical | Vice President of Clinical Services | Named in relation to conducting in-services and audits |
| Interim Administrator | Interim Facility Administrator | Named in relation to taking over administration and overseeing corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 28, 2018
Visit Reason
The inspection was conducted following a complaint investigation related to the care and treatment of Resident #77, who expired in the facility on 9/1/18, with concerns about adherence to Do Not Resuscitate (DNR) orders and nursing care.
Complaint Details
The investigation was triggered by concerns about the handling of Resident #77's emergency event on 9/1/18, specifically regarding initiation and cessation of CPR in relation to the resident's DNR order. Interviews with nursing staff revealed delays and confusion in verifying code status and stopping CPR. The resident expired on 9/1/18, and the facility did not complete a review of the death circumstances.
Findings
The facility failed to maintain an organized professional staff as required and did not properly follow the resident's DNR order during an emergency event. Resident #77 received CPR before staff verified the DNR status, and there was a lack of timely review of the circumstances surrounding the resident's death. Nursing care was not fully compliant with the resident's care plan and code status.
Deficiencies (4)
Failure to maintain an organized professional staff with required members and regular meetings.
Failure to honor resident's Do Not Resuscitate (DNR) order promptly during emergency response.
Lack of review of circumstances surrounding resident's death by Director of Nursing.
Nursing care not provided according to resident's needs and care plan, including failure to properly document and follow DNR status.
Report Facts
Date of resident admission: Oct 20, 2011
Date of resident death: Sep 1, 2018
Date of DNR order: Nov 8, 2011
Date of care plan initiation for no CPR: Nov 23, 2011
Date of survey completion: Nov 28, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Nurse involved in CPR initiation and verification of DNR status for Resident #77 |
| LPN BB | Licensed Practical Nurse | Nurse who performed chest compressions before being informed of DNR status |
| CNA CC | Certified Nursing Assistant | Reported resident was nonresponsive and alerted nursing staff |
| DON | Director of Nursing | Did not complete review of circumstances surrounding Resident #77's death |
| Administrator | Facility Administrator | Provided information on facility procedures for handling DNR status and emergency codes |
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 7
Date: Nov 17, 2018
Visit Reason
An Extended Recertification survey was conducted to assess compliance with Medicare/Medicaid regulations and investigate a change in condition and subsequent death of Resident #77.
Findings
The facility was found not in substantial compliance due to failure to follow advance directive orders, specifically performing CPR on a resident with a Do Not Resuscitate (DNR) order. There were also failures in notification of changes, comprehensive care planning, professional standards of care, administration, and quality assurance processes. Substandard quality of care was identified.
Deficiencies (7)
Failure to ensure follow-up procedures for advance directives and failure to maintain accurate advance directive documentation.
Failure to notify physician in a timely manner of significant change in condition of Resident #77.
Failure to follow plan of care related to advance directives when CPR was performed on Resident #77 who had a DNR order.
Failure to provide services meeting professional standards, including verifying advance directives and appropriate CPR initiation/cessation.
Failure of administration to effectively monitor advance directive system, ensure staff training, and conduct effective quality assurance.
Failure of Quality Assurance and Performance Improvement committee to identify and correct quality deficiencies related to advance directives.
Failure to provide basic life support in accordance with resident's advance directives, resulting in CPR being initiated on a resident with a DNR order.
Report Facts
Resident census: 78
Residents identified as DNR: 8
Date of survey completion: Nov 17, 2018
Date of incident: Sep 1, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Nurse who assessed Resident #77 and initiated CPR before verifying DNR status |
| LPN BB | Licensed Practical Nurse | Nurse who performed chest compressions on Resident #77 before CPR was stopped |
| CNA CC | Certified Nursing Assistant | Found Resident #77 unresponsive and initiated notification of nursing staff |
| Administrator | Facility Administrator | Responsible for facility oversight and training; acknowledged failures in monitoring advance directives and quality assurance |
| Social Worker | Responsible for advance directive follow-up and education | |
| Director of Nursing | Director of Nursing | Facility DON involved in notification and oversight |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 17, 2018
Visit Reason
The inspection was conducted to investigate a complaint related to the care and handling of Resident #77, who had a Do Not Resuscitate (DNR) order and expired in the facility on 9/1/18. The investigation focused on the circumstances surrounding the resident's death and compliance with professional and nursing care standards.
Complaint Details
The complaint investigation focused on Resident #77, who had a DNR order but received CPR before the code status was verified. Interviews with nursing staff revealed confusion and incomplete documentation regarding the resident's death and notification procedures. The complaint was substantiated based on these findings.
Findings
The facility failed to maintain an organized professional staff as required and did not properly review the circumstances surrounding Resident #77's death. The resident had a DNR order, but CPR was initially started before the code status was verified, leading to confusion and delayed cessation of resuscitation efforts. Documentation and notification processes were incomplete or missing.
Deficiencies (3)
Failure to maintain an organized professional staff with required members and regular meetings.
Failure to properly review and document circumstances surrounding Resident #77's death.
Inadequate nursing care related to initiation and cessation of CPR for a resident with a DNR order.
Report Facts
Date of resident admission: Oct 20, 2011
Date of resident death: Sep 1, 2018
Date of DNR order: Nov 8, 2011
Date of care plan initiation for no CPR: Nov 23, 2011
Date of survey completion: Nov 17, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Involved in CPR initiation and cessation for Resident #77; checked code status and notified family, MD, and coroner. |
| LPN BB | Licensed Practical Nurse | Performed chest compressions on Resident #77 before code status was verified; stopped CPR upon notification of DNR. |
| CNA CC | Certified Nursing Assistant | Reported Resident #77 was nonresponsive and assisted in notifying nursing staff. |
| DON | Director of Nursing | Interviewed regarding review of circumstances surrounding Resident #77's death; stated no review was completed. |
| Administrator | Facility Administrator | Provided information on facility procedures for handling unresponsive residents and DNR status. |
Inspection Report
Life Safety
Census: 81
Capacity: 90
Deficiencies: 12
Date: Nov 14, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including handrail maintenance, exit lighting testing, emergency lighting testing, fire alarm system maintenance, sprinkler system maintenance, corridor door integrity, smoke barrier construction, rated wall and ceiling penetrations, electrical system safety, HVAC makeup air, fire door inspections, and generator maintenance. These deficiencies could place residents at risk in the event of an emergency.
Deficiencies (12)
Facility failed to properly maintain handrails; exterior stairs handrail removed placing 46 residents at risk.
Facility failed to properly maintain illumination of means of egress; exit lighting not tested monthly or annually.
Facility failed to properly maintain emergency lighting; emergency lighting not tested monthly or annually.
Facility failed to properly maintain fire alarm system; missing smoke detector, unlabeled breaker, unmarked batteries, and unlabeled alarm circuit.
Facility failed to properly maintain fire sprinkler system; improperly installed heads, heads loaded with dust and grease, and obstructed sprinkler heads.
Facility failed to properly maintain corridor doors; sleeping room door 211 does not create smoke resistant seal.
Facility failed to properly maintain corridor rated doors; second floor corridors do not close fully and first floor doors have excessive gaps.
Facility failed to properly maintain rated walls, ceilings, and floor penetrations; improper fire protection products, holes, missing rated ceilings, and unprotected penetrations.
Facility failed to properly maintain electrical systems; flexible power cords run through walls and ceilings.
Facility failed to properly maintain HVAC system; fuel fired furnace lacks outside makeup air.
Facility failed to properly maintain fire door inspections; no routine inspections of rated doors.
Facility failed to properly maintain emergency generator; no remote annunciator and no monthly load runs.
Report Facts
Residents at risk due to handrail deficiency: 46
Census: 81
Total licensed beds: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during facility tour |
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 0
Date: Feb 12, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey on 12/14/2018.
Findings
All deficiencies cited as a result of the Recertification survey on 12/14/2018 were found to be corrected.
Inspection Report
Life Safety
Census: 69
Capacity: 80
Deficiencies: 0
Date: Dec 14, 2017
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition.
Findings
Westminster Commons was found in substantial compliance with the emergency preparedness plan requirements and Life Safety Code standards during the survey.
Report Facts
Stories: 2
Construction Type: 1332
Certified Beds: 80
Census: 69
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 2, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00179826 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00179826 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted on October 2, 2017.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 6, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00172242 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00172242 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey at Westminster Commons.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00169145 and to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00169145 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
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