Inspection Reports for Westminster Commons

A revisit survey was conducted from July 7, 2025, through July 8, 2025, including investigation of two complaint intake numbers GA00255240 and GA00255301.

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.

Complaint Intake Numbers GA00255240 and GA00255301 were investigated and found to be unsubstantiated.

A revisit survey was conducted from July 7, 2025, through July 8, 2025, in conjunction with investigation of two complaint intake numbers.

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.

Complaint Intake Numbers GA00255240 and GA00255301 were investigated and found to be unsubstantiated.

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.

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.

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.

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.

A recertification survey was conducted at Westminster Commons from May 19, 2025, through May 22, 2025, including investigation of multiple complaint intake numbers.

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.

Multiple complaint intake numbers were investigated in conjunction with the standard survey, including allegations of neglect, abuse, and improper care.

An abbreviated/partial extended survey was conducted to investigate complaints GA00251397 and GA00251418.

Complaint GA00251397 was unsubstantiated, and complaint GA00251418 was substantiated with no deficiencies cited.

Complaint GA00251397 was unsubstantiated; complaint GA00251418 was substantiated with no deficiencies cited.

This document is a Statement of Deficiencies and Plan of Correction for Westminster Commons, indicating regulatory oversight and corrective actions following an inspection.

The report contains initial comments but does not specify any detailed deficiencies or findings within the provided page.

A revisit survey was conducted to verify correction of deficiencies cited during a Complaint Survey on September 5, 2024.

All deficiencies cited as a result of the September 5, 2024 Complaint Survey were found to be corrected during the revisit survey.

The revisit survey was conducted following a Complaint Survey on September 5, 2024. All cited deficiencies were corrected.

A State Licensure survey was conducted at Westminster Commons from August 28, 2024, through September 5, 2024, to assess compliance with state health regulations.

The survey revealed that there were no State Health deficiencies cited during the inspection period.

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.

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.

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.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00247037.

The complaint was unsubstantiated and no deficiencies were cited during the survey.

Complaint #GA00247037 was investigated and found to be unsubstantiated with no deficiencies cited.

The document is a Statement of Deficiencies and Plan of Correction for Westminster Commons, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide detailed findings or deficiencies.

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.

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.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

All previously cited survey tags have been corrected as noted by the surveyor.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Complaint Intake Numbers GA00241382, GA00239275, GA00239870, GA00234006, and GA00233353 were investigated in conjunction with the standard survey and were found to be unsubstantiated.

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.

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.

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.

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.

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).

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.

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).

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.

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).

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.

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).

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.

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).

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.

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).

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.

This document is a Statement of Deficiencies and Plan of Correction for Westminster Commons, indicating a regulatory inspection was conducted.

The report contains initial comments but does not specify any detailed deficiencies or findings.

A revisit survey was conducted on 8/17/22 to verify correction of deficiencies cited during the 6/3/22 recertification survey.

All deficiencies cited as a result of the 6/3/22 recertification survey were found to be corrected.

A revisit survey was conducted on 8/17/22 in conjunction with investigation of Complaint intake Number GA00225816.

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.

Complaint intake Number GA00225816 was investigated and found to be unsubstantiated with no deficiencies.

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).

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.

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).

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.

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).

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.

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).

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.

The inspection was conducted as a Licensure Survey from 5/31/22 through 6/3/22 to assess compliance for facility licensure renewal.

No deficiencies were identified during the licensure survey.

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.

Westminister Commons was found in substantial compliance with the requirements for participation in Medicare/Medicaid and the related Life Safety Code standards.

A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating complaint #GA00212715.

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.

Complaint #GA00212715 was substantiated with no regulatory violations.

An abbreviated/partial extended survey was conducted to investigate multiple complaints identified by their numbers.

The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.

Complaints #GA00211821, #GA00208143, #GA00206292, #GA00206103, #GA00204859, #GA00203685, #GA00205795, and #GA00211819 were investigated and found to be unsubstantiated.

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.

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.

A revisit survey was conducted to verify correction of deficiencies cited during the 3/11/2020 Complaint Survey.

All deficiencies cited as a result of the 3/11/2020 Complaint Survey were found to be corrected.

The visit was a follow-up to a complaint survey conducted on 3/11/2020; all cited deficiencies were corrected.

A revisit survey was conducted on 08/10/2020 to verify correction of deficiencies cited during the 03/11/2020 complaint survey.

All deficiencies cited as a result of the 03/11/2020 complaint survey were found to be corrected during this revisit survey.

The revisit survey was conducted following a complaint survey on 03/11/2020; all cited deficiencies were corrected.

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.

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.

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.

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.

Complaint intake number GA00203599 was investigated and substantiated with cited deficiencies including Substandard Quality of Care.

The document is a statement of deficiencies and plan of correction for Westminster Commons, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details on deficiencies or findings.

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.

All deficiencies identified in the 2020-01-09 survey were found to be corrected during this revisit survey.

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.

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.

The deficiencies were identified during a complaint survey triggered by concerns about unlocked medication and supply rooms and unattended housekeeping carts with accessible chemicals.

An abbreviated/partial extended survey was conducted to investigate complaints GA00201842, GA00201066, and GA00200709, with substantiation of federal violations related to complaint GA00201066.

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.

The investigation was initiated due to complaints GA00201842, GA00201066, and GA00200709. GA00201066 was substantiated with federal violations cited.

An Abbreviated/Partial Extended licensure survey was conducted to investigate complaint numbers GA00201842, GA00201066, and GA00200709.

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.

The survey investigated complaints GA00201842, GA00201066, and GA00200709.

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.

No deficiencies were cited during the complaint investigation survey.

The survey was conducted in response to complaints GA00196123 and GA00195816; no deficiencies were found.

A follow-up survey was conducted to verify that all previously cited deficiencies had been corrected.

The follow-up survey noted that all previously cited tags had been corrected.

A revisit survey was conducted to verify correction of deficiencies cited during the extended recertification survey conducted in November 2018.

All deficiencies cited in the prior extended recertification survey were found to be corrected during this revisit survey.

A follow-up survey was conducted to verify correction of previously cited deficiencies.

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.

An abbreviated survey was conducted to investigate complaint numbers GA00193197 and GA00193494.

The complaints GA00193197 and GA00193494 were investigated and found to be unsubstantiated.

Complaint numbers GA00193197 and GA00193494 were investigated and found to be unsubstantiated.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.

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.

A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey on 12/14/2018.

All deficiencies cited as a result of the Recertification survey on 12/14/2018 were found to be corrected.

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.

Westminster Commons was found in substantial compliance with the emergency preparedness plan requirements and Life Safety Code standards during the survey.

The inspection was conducted to investigate complaint #GA00179826 to determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey conducted on October 2, 2017.

Complaint #GA00179826 was investigated and found to have no deficiencies.

The inspection was conducted to investigate complaint #GA00172242 and determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey at Westminster Commons.

Complaint #GA00172242 was investigated and found to have no deficiencies.

The inspection was conducted to investigate complaints #GA00169145 and to determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey.

Complaint #GA00169145 was investigated and found to have no deficiencies.