Inspection Reports for
Westminster St. Augustine

Across the inspection history, 6 deficiencies were recorded, none in the two most serious classes, and no legal actions were taken.

The investigation was triggered by complaints from Resident #4 about missing nightgowns and Resident #7 about discomfort with her wheelchair. Both grievances were not properly documented or resolved according to facility policy. The Social Services Director and other staff confirmed lack of grievance documentation and follow-up.

The facility failed to properly record, address, and resolve grievances for two residents regarding missing personal items and wheelchair discomfort. Additionally, the facility failed to ensure proper hand hygiene and use of personal protective equipment during care of a resident with a PICC line.

No health deficiencies were found during the inspection.

The complaint investigation found that the facility did not have current orders or documentation for behavior monitoring for antipsychotic medications for Resident #16. The Director of Nursing confirmed missing documentation and noted that electronic medical records sometimes dropped orders. Previous reviews of antipsychotic monitoring had occurred but not recently.

The facility failed to monitor behaviors for one resident receiving antipsychotic medication as required. Documentation and orders for behavior monitoring were missing despite active medication orders and care plan interventions.