Inspection Reports for
Westminster Terrace

The inspection found no deficiencies in the areas inspected, including resident care, physical plant, fire safety, medication administration, and facility cleanliness. All required documentation was present and the facility met regulatory standards.

The inspection found no deficiencies in the areas inspected, including resident care, physical plant, fire safety, medication storage and administration, and overall facility conditions. All required documentation was present and the facility was found to be in compliance with regulations.

The complaint investigation addressed allegations that staff did not provide adequate food service, residents were not treated with respect and dignity, and residents were not given comfortable dining accommodations. Each allegation was investigated through tours, interviews, and policy reviews, and all were determined to be unsubstantiated.

The investigation included multiple tours, resident interviews, and documentation reviews. All three main allegations— inadequate food service, lack of respect and dignity towards residents, and uncomfortable dining accommodations—were found to be unsubstantiated due to insufficient evidence to prove or refute the claims.

The complaint investigation addressed three main allegations: 1) Staff did not provide adequate food service, including complaints about food temperature and service quality; 2) Residents were not treated with respect and dignity, including reports of rude staff and delayed meal service; 3) Residents were not given comfortable dining accommodations, including seating issues and food quality concerns. All allegations were determined to be unsubstantiated.

The investigation included multiple tours, resident interviews, and document reviews. All allegations—regarding food service quality and temperature, staff treatment of residents, and dining accommodations—were found to be unsubstantiated due to insufficient evidence to prove or refute the complaints.

The complaint investigation addressed three main allegations: 1) Staff leaving residents soiled for extended periods; 2) Staff not responding to resident calls for assistance in a timely manner; 3) Delay of three months in fixing a broken air conditioner in a resident's apartment. All allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The investigation found all allegations unsubstantiated, including claims that staff left residents soiled for extended periods, did not respond timely to resident calls, and delayed repair of a broken air conditioner. Evidence was insufficient to prove violations occurred.

The complaint investigation addressed three main allegations: 1) Staff leaving residents soiled for extended periods due to shift change delays; 2) Staff not responding timely to resident calls for assistance, with issues related to call pendant functionality; 3) Delay of approximately three months to repair/replace a broken air conditioner in a resident's apartment. All allegations were determined to be unsubstantiated based on the evidence gathered.

The investigation found all allegations unsubstantiated, including claims that staff left residents soiled for extended periods, did not respond timely to resident calls, and delayed repair of a broken air conditioner. Evidence did not support that violations occurred.

The complaint involved allegations that staff did not follow doctor's orders, mismanaged resident medications, and failed to administer medications as prescribed. The investigation included interviews with staff and residents and review of physician orders and medication records. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The investigation found that the allegations were unsubstantiated. Staff followed physician orders, medications were administered within an accepted one-hour grace period, and residents generally received medications as prescribed. Conflicting physician reports regarding a resident's medication self-administration were clarified during the investigation. No deficiencies were cited.

The complaint was unsubstantiated based on interviews with staff and residents, review of physician orders, medication administration records, and observations. Staff and residents confirmed adherence to physician orders and proper medication management.

The investigation found that the allegations were unsubstantiated. Staff followed physician orders, medications were administered within an accepted one-hour grace period, and residents generally received medications as prescribed. Conflicting physician reports regarding a resident's ability to self-administer medications were clarified during the investigation.

The complaint alleged that facility staff failed to address a resident's prohibited health condition adequately. The investigation included review of incident reports, hospital discharge paperwork, staff and resident interviews, and observations. The allegation was found to be unfounded.

The investigation found the allegation to be unfounded. Staff followed infection control protocols by sending the resident back to the hospital upon suspicion of infectious disease, and no infectious disease cases were confirmed in the facility.

During the inspection, no health or safety issues were observed in the facility or Resident 1's room. No deficiencies were cited at this time.

The complaint alleged that facility staff interfered with the resident council by stealing and copying meeting minutes and retaliating against residents, and that staff did not safeguard residents' personal belongings. The investigation included interviews with residents and staff, document reviews, and observations. The allegations were determined to be unsubstantiated due to lack of sufficient evidence.

The investigation found the allegations of staff interfering with the resident council and not safeguarding residents' personal belongings to be unsubstantiated. Interviews with residents and staff, observations, and record reviews did not support the claims. No deficiencies were cited.

The complaint investigation was unannounced and conducted by Licensing Program Analyst Michael Tea. Allegations included inadequate medication assistance, untimely response to resident calls, and failure to safeguard personal belongings. The investigation included interviews with residents and staff, review of call logs, and observations. The allegations were determined to be unsubstantiated or unfounded based on evidence and interviews.

The investigation found that although some residents reported occasional delays in medication administration and response times, and concerns about safeguarding personal belongings, there was insufficient evidence to substantiate the allegations. Staff were observed to respond within adequate timeframes, and protocols for safeguarding belongings were followed. The allegations were determined to be unsubstantiated or unfounded, and no deficiencies were cited.

The complaint investigation was unsubstantiated based on observations, interviews, and record reviews. Allegations included medication mismanagement and inadequate room sanitation, but evidence did not support these claims.

The investigation found no evidence to substantiate the allegations. Medication administration records and interviews confirmed medications were given as prescribed, and the facility's housekeeping practices were generally satisfactory with no observed cleanliness issues in the resident's room.

The complaint alleged that the facility was not changing residents' sheets on a regular weekly basis. After investigation, including interviews with the Executive Director, staff, and residents, and review of linen supply invoices, the complaint was determined to be unsubstantiated.

Based on observations, interviews with staff and residents, and review of linen supply invoices, the allegation that the facility was not changing residents' sheets weekly was determined to be unsubstantiated. No deficiencies were cited during this visit.

The inspection found no deficiencies in the areas inspected. Resident files, staff files, physical plant, fire safety, medication storage, and resident care were all in compliance with regulations.

The complaint investigation was unsubstantiated, meaning there was insufficient evidence to prove the alleged violations of scabies infestation, medication mismanagement, and infection control plan noncompliance.

The investigation found that only one resident was diagnosed with scabies and there was no evidence of an infestation. Medication administration was found to be properly managed and documented. The facility followed infection control protocols promptly when scabies was suspected. Overall, the allegations were determined to be unsubstantiated.

During the inspection, no health or safety issues were observed, the facility was clean and organized, and no deficiencies were cited at this time.

The complaint investigation was unsubstantiated due to conflicting information and lack of preponderance of evidence to prove or refute the allegations.

The investigation found conflicting information regarding the allegations. Some residents and staff confirmed or denied the complaints, and document reviews supported staff training and policies protecting resident rights. Due to insufficient evidence, all allegations were deemed unsubstantiated, and no citations were issued.

The complaint investigation was unsubstantiated. Allegations included residents fearing retaliation and understaffing. Interviews with 7 residents and staff did not support these allegations. Staffing schedules confirmed adequate coverage. No preponderance of evidence was found to prove or refute the allegations.

The investigation included interviews with residents and staff, a tour of the facility, and review of records. The allegations were not substantiated as resident and staff interviews did not corroborate the claims, and staffing levels were verified as adequate through staff schedules and observations.

The complaint investigation was unsubstantiated. Allegations included failure to provide laundry service and clean bed linens to Resident 1. Evidence showed laundry service was resumed and linens were changed regularly, but no conclusive proof of violation was found.

The investigation found that laundry service for Resident 1 had been stopped on January 1, 2024, but resumed around March 8, 2024, with the facility assisting once a week. Bed linens were reported to be changed about once a week by staff or family. Both allegations were deemed unsubstantiated due to lack of preponderance of evidence.

The facility was toured and found to be in compliance with regulatory requirements including adequate supplies, clean and hazard-free common areas, proper food storage, locked medication and toxin storage, and functional call systems. The facility is ready to be licensed.

The applicant/administrator demonstrated understanding of licensing requirements including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness during the COMP II telephone interview.