Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 6
Date: Aug 14, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements for nursing home care, including resident rights, PASARR screening, activities of daily living assistance, meal assistance, medication administration, and equipment safety.
Findings
The facility was found deficient in multiple areas including failure to document advance directives, incomplete PASARR screenings, delayed assistance with toileting and meals for residents, a medication error rate exceeding 5%, and failure to maintain dishwashing machine temperatures per manufacturer specifications.
Deficiencies (6)
F578: The facility failed to ensure Resident #45 had a current advance directive and Power of Attorney documentation in the medical record.
F645: The facility failed to complete and update PASARR screenings for residents #3 and #10 with qualifying mental health diagnoses.
F676: Resident #48 did not receive timely toileting assistance due to staff not locating the bed pan and staffing assignments.
F677: The facility failed to provide meal assistance to Residents #39 and #45 during observed meal times, resulting in delayed feeding and lack of encouragement.
F759: The medication error rate was 18.75% with six errors observed during medication administration for Resident #29.
F908: The dish washing machine failed to reach the required wash temperature of 160°F, operating at 139-145°F, compromising sanitation.
Report Facts
Medication opportunities observed: 32
Medication errors identified: 6
Medication error rate: 18.75
Wash cycle temperature: 139
Wash cycle temperature: 145
Rinse cycle temperature: 195
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Social Worker | Interviewed regarding Resident #45's advance directive and POA documentation |
| Staff H | Social Services Director | Interviewed regarding Resident #45's advance directive and PASARR screenings |
| Staff T | Certified Nursing Assistant | Interviewed regarding delayed toileting assistance for Resident #48 |
| Staff U | Registered Nurse | Interviewed regarding toileting assistance and bed pan availability for Resident #48 |
| Staff B | Registered Nurse | Observed and interviewed regarding meal assistance for Residents #39 and #45 |
| Staff A | Licensed Practical Nurse/Supervisor | Interviewed regarding meal assistance and supervision in dining room |
| Staff C | Speech Therapist | Interviewed regarding feeding assistance and encouragement for Resident #45 |
| Staff P | Registered Nurse | Observed administering medications to Resident #29 |
| Staff O | Licensed Practical Nurse | Interviewed regarding medication administration timing |
| Staff N | Outsourced Maintenance Personnel | Interviewed regarding dish washing machine temperature issues |
| Kitchen Manager | Interviewed regarding dish washing machine operation and temperature monitoring | |
| Director of Nursing | DON | Interviewed regarding medication administration and dining room supervision |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 10, 2025
Visit Reason
The inspection was conducted due to allegations of abuse and neglect involving three residents. The facility was investigated for failure to timely implement policies and procedures related to reporting alleged abuse and neglect incidents.
Complaint Details
The complaint investigation involved three residents with allegations of neglect and abuse. Resident #1 did not receive medications for two days, Resident #2's family alleged neglect related to high blood pressure medication, and Resident #3 reported delayed pain medication. Some allegations were substantiated, others were not, and reporting to DCF was often late.
Findings
The facility failed to timely report and properly manage abuse and neglect allegations for three residents. Issues included delayed reporting to the Department of Children and Families (DCF), failure to provide medications, and inadequate protection of residents during investigations.
Deficiencies (2)
F 0607: The facility failed to implement timely their Abuse, Neglect and Exploitation policy related to reporting alleged abuse and neglect incidents for three residents. Reporting to DCF was delayed beyond required timeframes, and medication administration procedures were not followed.
Nobody ever puts medications on hold. If there was an issue, then the Director of Nursing needs to be notified.
Report Facts
Date notified of allegation: May 15, 2025
Date notified of allegation: Jun 1, 2025
Date notified of allegation: Jun 5, 2025
Date reported to DCF: May 15, 2025
Date reported to DCF: Jun 3, 2025
Date reported to DCF: Jun 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding allegations and reporting delays |
| Staff A | Licensed Practical Nurse (LPN) | Reported working on Percocet prescription for Resident #3 |
| Staff B | Registered Nurse (RN) | Admitting nurse for Resident #3, not interviewed |
| Staff C | Licensed Practical Nurse (LPN) | Confirmed medication holds and communication with Nurse Practitioner |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
Annual survey inspection of Westminster Point Pleasant nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 27, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, including eating assistance, adaptive equipment use, contracture management, and respiratory care.
Findings
The facility failed to consistently provide adaptive eating equipment and assistance during meals for Resident #83, and failed to ensure contracture management splints were used as ordered for Resident #36. Additionally, oxygen therapy orders were not followed correctly for Resident #52, with oxygen concentrator settings exceeding prescribed levels.
Deficiencies (3)
F 0656: The facility failed to implement care plan interventions for Resident #83 by not providing adaptive eating equipment and assistance during meals, and for Resident #36 by not offering or assisting with braces/splints for contracture management.
F 0676: The facility failed to ensure eating assistance and adaptive eating equipment was provided for Resident #83 as ordered, resulting in inconsistent care during meal times.
F 0695: The facility failed to provide respiratory care consistent with physician orders for Resident #52 by setting the oxygen concentrator at 3.5 liters per minute instead of the ordered 2 liters per minute.
Report Facts
Order for oxygen flow rate: 2
Observed oxygen flow rate: 3.5
Resident #83 meal observation: 50
MDS BIMS score: 15
MDS BIMS score: 3
Splint usage order: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed assisting Resident #83 with feeding and reported removal of adaptive eating equipment. |
| Staff B | Speech Therapist | Interviewed regarding Resident #83's swallowing and feeding needs. |
| Staff C | MDS Coordinator | Interviewed regarding care planning and feeding assistance for Resident #83 and contracture management for Resident #36. |
| Staff D | MDS Coordinator | Interviewed alongside Staff C regarding Resident #83 and Resident #36 care plans. |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #36's splint use and care. |
| Staff G | Licensed Practical Nurse (LPN) | Observed oxygen concentrator setting error for Resident #52 and confirmed incorrect flow rate. |
Inspection Report
Routine
Deficiencies: 2
Date: May 27, 2021
Visit Reason
The inspection was conducted to evaluate compliance with medication storage, labeling, and administration policies, as well as food storage and sanitation standards in the facility.
Findings
The facility failed to ensure proper labeling and storage of drugs and biologicals, including undated opened medications, unlocked medication carts, and loose pills. Additionally, medications were improperly left in resident rooms. The facility also failed to store and maintain food safely and sanitarily in refrigerators and freezers, including moldy lemons and uncovered garlic.
Deficiencies (2)
F 0761: The facility failed to ensure drugs and biologicals were properly labeled and stored in locked compartments. Multiple medication carts and storage rooms contained undated opened medications, loose pills, and unlocked carts. Medications were also left unsecured in resident rooms.
F 0812: The facility failed to procure food from approved sources and store, prepare, distribute, and serve food in a safe and sanitary manner. Observations included moldy lemons and uncovered garlic stored improperly in refrigerators and freezers.
Report Facts
Loose medications observed: 11
Medication carts inspected: 3
Medication storage rooms inspected: 2
Residents observed: 2
Days after opening expiration: 42
Days after opening expiration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Named in medication cart inspection and medication labeling issues. |
| Staff C | Assistant Director of Nursing (ADON) | Participated in medication storage room inspection and discussed staff education. |
| Staff A | Registered Nurse (RN) | Conducted medication cart inspection and involved in medication administration to Resident #66. |
| Staff D | Licensed Practical Nurse (LPN) | Involved in medication cart inspection and medication labeling observations. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding medication storage and administration policies and observations. |
| Nursing Home Administrator (NHA) | Nursing Home Administrator | Interviewed regarding medication storage and administration policies and observations. |
| Certified Dietary Manager (CDM) | Certified Dietary Manager | Confirmed food storage violations during kitchen tour. |
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