7 Reports
Inspection Report — Jun 3, 2026
Complaint Investigation
Date: Jun 3, 2026
Visit Reason
The page covers the inspection history of Westminster Towers including complaint and standard visits with outcomes.
Findings
Across 24 inspections from July 18, 2012 to June 3, 2026, 8 visits cited deficiencies totaling 36 findings, none serious. Three legal actions with fines totaling $1,500 were recorded.
Citations (36)
Resident Care - Supervision — cited February 18, 2026, corrected June 3, 2026
Medication - Storage and Disposal — cited January 5, 2026, corrected February 18, 2026
Training - Staff In-service — cited January 5, 2026, corrected February 18, 2026
Reporting Requirements; Electronic Submission — cited January 5, 2026, corrected February 18, 2026
Licensure - Requirements — cited June 9, 2021, corrected August 26, 2021
Resident Care - Elopement Standards — cited June 9, 2021, corrected August 26, 2021
Training - Assis Self-admin Meds & Med Mgmt — cited June 9, 2021, corrected August 26, 2021
Training - Nutrition & Food Service — cited June 9, 2021, corrected August 26, 2021
Food Service - Dietary Standards — cited June 9, 2021, corrected August 26, 2021
ECC - Service Plans — cited June 9, 2021, corrected August 26, 2021
ECC - Records — cited June 9, 2021, corrected August 26, 2021
Background Screening Clearinghouse — cited June 9, 2021, corrected August 26, 2021
Admissions - Health Assessment — cited October 2, 2019, corrected November 20, 2019
Admissions - Continued Residency — cited October 2, 2019, corrected November 20, 2019
Resident Care - Supervision — cited October 2, 2019, corrected November 20, 2019
Medication - Records — cited October 2, 2019, corrected November 20, 2019
Emergency Environmental Control — cited October 2, 2019, corrected November 20, 2019
ECC - Training — cited October 2, 2019, corrected November 20, 2019
Background Screening Clearinghouse — cited October 2, 2019, corrected November 20, 2019
Staffing Standards - Staff — cited August 23, 2018, corrected November 1, 2018
Training - Staff In-service — cited August 23, 2018, corrected November 1, 2018
Training - Assis Self-admin Meds & Med Mgmt — cited August 23, 2018, corrected November 1, 2018
Training - Do Not Resuscitate Orders — cited August 23, 2018, corrected November 1, 2018
ECC - Training — cited August 23, 2018, corrected November 1, 2018
Staffing Standards - Staff — cited April 20, 2017, corrected June 20, 2017
Training - Assis Self-admin Meds & Med Mgmt — cited April 20, 2017, corrected June 20, 2017
Training - Do Not Resuscitate Orders — cited April 20, 2017, corrected June 20, 2017
Medication - Assistance With Self-admin — cited September 29, 2015, corrected January 21, 2016
Staffing Standards - Staff — cited September 29, 2015, corrected January 21, 2016
Training - First Aid and Cpr — cited September 29, 2015, corrected January 21, 2016
Food Service - Dietary Standards — cited September 29, 2015, corrected January 21, 2016
ECC - Health Assessment — cited September 29, 2015, corrected January 21, 2016
ECC - Records — cited September 29, 2015, corrected January 21, 2016
Training - Staff In-service — cited October 3, 2013, corrected December 16, 2013
Training - Hiv/aids — cited October 3, 2013, corrected December 16, 2013
Training - Do Not Resuscitate Orders — cited October 3, 2013, corrected December 16, 2013
Report Facts
Inspections: 24
Visits with deficiencies: 8
Clean visits: 7
Deficiencies: 36
Serious deficiencies: 0
Legal actions: 3
Total fines: 1500
Inspection Report — Mar 13, 2025
Routine
Date: Mar 13, 2025
Visit Reason
Routine inspection of Westminster Towers nursing home to assess compliance with regulatory requirements including medication self-administration, care planning, activities of daily living, medication administration, care coordination, and documentation.
Findings
The facility failed to ensure proper self-administration of medications, timely provision of baseline care plan summaries, adherence to shower schedules, compliance with medication administration parameters, coordination of specialist care, and accurate documentation of incidents. Deficiencies were identified in multiple areas affecting a few to some residents.
Citations (6)
F 0554: The facility failed to ensure residents self-administered medications only when clinically appropriate and with physician orders, as two residents had unauthorized medications at bedside.
F 0655: The facility failed to provide a written summary of the baseline care plan within 48 hours of admission for two residents, and signatures verifying receipt were missing.
F 0677: The facility failed to provide showers per resident preference and schedule for one resident, who missed multiple scheduled showers without documented refusals.
F 0684: The facility failed to follow physician orders for medication administration, administering Hydralazine outside ordered heart rate parameters multiple times for one resident.
F 0840: The facility failed to obtain an outside eye specialist appointment for one resident despite physician orders and documented eye complaints.
F 0842: The facility failed to maintain accurate and complete documentation for one resident's wandering incident, with no incident report or clinical record entries found.
Report Facts
Residents reviewed for self-administration: 33
Residents reviewed for care plans: 34
Residents reviewed for ADLs: 34
Residents reviewed for medication regimen: 34
Hydralazine doses administered outside parameters: 40
Scheduled showers missed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Primary Registered Nurse | Acknowledged unauthorized medication on resident #57's nightstand |
| RN D | 3:00-11:00 PM Supervisor | Acknowledged no physician orders for Voltaren cream for resident #83 and secured medication |
| Director of Nursing | Director of Nursing (DON) | Acknowledged policies on medication self-administration and care plan procedures; explained expectations on medication administration and shower refusals |
| Social Service Director | Social Service Director (SSD) | Explained baseline care plan process and care coordination for eye specialist consult |
| 2nd Floor Unit Assistant Director of Nursing | ADON | Completed baseline care plans and acknowledged missing resident signatures |
| CNA E | Certified Nursing Assistant | Reported resident #75 refused showers and agreed to bed baths |
| CNA F | Certified Nursing Assistant | Reported resident #75 required transfer assistance and sometimes refused showers |
| LPN H | Licensed Practical Nurse | Administered Hydralazine outside ordered parameters and acknowledged misunderstanding of current orders |
| RN G | Registered Nurse | Reported no awareness of shower refusals for resident #75 |
| Administrator | Facility Administrator | Discussed resident wandering incident and documentation issues |
| RN A | Registered Nurse Supervisor | Reported receiving information about resident wandering incident |
Inspection Report — Mar 4, 2025
Complaint Investigation
Date: Mar 4, 2025
Visit Reason
The investigation was conducted due to a complaint regarding failure to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) and verification of code status for a resident receiving hospice care.
Complaint Details
The complaint investigation found that a resident receiving hospice care with a Full Code status was not resuscitated when found unresponsive. The failure to verify code status and initiate CPR was substantiated. Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to honor the wishes of a resident who was a Full Code by not providing CPR when the resident was found unresponsive, resulting in Immediate Jeopardy to resident health or safety. Corrective actions including staff education, audits, and code blue drills were implemented, and the Immediate Jeopardy was removed after these measures.
Citations (1)
F 0678: Licensed nurses failed to follow the facility's CPR policy by not verifying the code status and not providing CPR to a resident who was a Full Code, resulting in Immediate Jeopardy to resident health or safety.
Report Facts
Licensed nurses educated: 64
Licensed nurses educated: 48
Licensed nurses educated: 10
Licensed nurses educated: 6
Licensed nurses total: 81
Residents reviewed: 13
Additional residents reviewed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in failure to verify code status and not initiating CPR for resident #1. |
| RN C | Registered Nurse | Assisted RN A with postmortem care and was involved in the incident. |
| RN Supervisor B | RN Supervisor | Supervised shift during incident and received training on code status verification. |
| Administrator | Notified of the incident and discrepancies in documentation. | |
| Director of Nursing | Director of Nursing | Involved in investigation and staff education following the incident. |
Inspection Report — Aug 21, 2024
Complaint Investigation
Date: Aug 21, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an alleged neglect incident involving a resident who eloped from the facility.
Complaint Details
The complaint investigation was substantiated. The facility failed to timely report an alleged neglect incident involving resident #1 who eloped from the facility on 8/07/24. The report was filed late on 8/08/24. The resident disabled her wander/elopement alarm and left the facility unsupervised, walking to a nearby hospital.
Findings
The facility failed to timely report an alleged neglect incident involving resident #1 who left the facility unsupervised and walked to a nearby hospital. The investigation revealed inadequate supervision and failure to check on the resident frequently despite her known risk for elopement. The resident disabled her wander/elopement alarm and swapped her walker to avoid detection.
Citations (2)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for 1 of 1 resident reviewed for neglect.
F 0689: The facility failed to provide adequate supervision to prevent elopement for 1 of 1 resident reviewed, despite known risk and use of wander/elopement alarms.
Report Facts
Resident sample size: 3
Brief Interview for Mental Status score: 10
Date of elopement: Aug 7, 2024
Date report filed: Aug 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Confirmed resident #1 was on her assignment the night of 8/06/24 and described resident's routine |
| CNA B | Certified Nursing Assistant | Assigned to resident #1 on 8/06/24 and observed resident's whereabouts during the evening |
| Dietary Aide E | Dietary Aide | Observed resident #1 entering elevator with him on 8/06/24 evening |
| CNA D | Certified Nursing Assistant | Worked night shift on 8/06/24 and performed routine rounds, did not find resident #1 in her room |
| LPN C | Licensed Practical Nurse | Assigned to resident #1 on night shift 8/06/24, arrived late and did not check on resident throughout the night |
| LPN F | Licensed Practical Nurse | Worked morning shift on 8/07/24, discovered resident #1 missing and called code for missing resident |
| Administrator | Facility Administrator | Responsible for filing reports and reviewed investigation findings |
| Director of Nursing | Director of Nursing | Participated in meeting reviewing investigation and findings |
Inspection Report — May 14, 2024
Routine
Date: May 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, pressure ulcer care, IV fluid administration, and medical record accuracy at Westminster Towers nursing home.
Findings
The facility failed to ensure a physician's order was obtained for medications stored at bedside, wound care for pressure ulcers was not consistently provided as ordered, PICC line dressings were not changed as per physician's orders, and medical records inaccurately documented PICC line dressing changes.
Citations (4)
F 0554: The facility failed to ensure a physician's order was obtained for medications stored at bedside for 1 of 3 residents reviewed for pressure ulcer care.
F 0686: The facility failed to ensure wound care for pressure ulcers was completed per physician's orders for 2 of 3 residents reviewed for pressure ulcers.
F 0694: The facility failed to ensure a Peripheral Inserted Central Catheter (PICC) line dressing was changed every 7 days as ordered for 1 of 8 residents.
F 0842: The facility failed to ensure medical records accurately reflected PICC line dressing changes for 1 of 1 residents reviewed for PICC lines.
Report Facts
Residents reviewed for pressure ulcer care: 3
Residents reviewed for pressure ulcers: 8
Residents reviewed for PICC lines: 8
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Primary nurse for resident #2, acknowledged medication and PICC line dressing issues |
| Director of Nursing | Director of Nursing | Acknowledged deficiencies related to wound care and PICC line dressing changes |
| Assistant Director of Nursing | Assistant Director of Nursing | Acknowledged medication and PICC line dressing deficiencies |
| Wound Care Registered Nurse | Wound Care Registered Nurse | Acknowledged missing wound care documentation |
| RN Supervisor | Registered Nurse Supervisor | Confirmed PICC line dressing documentation discrepancies |
Inspection Report — Aug 3, 2023
Annual Inspection
Date: Aug 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements for nursing home care, including resident rights, accurate assessments, pre-admission screening, and appropriate treatment and care.
Findings
The facility was found deficient in honoring resident shower preferences, completing accurate Minimum Data Set assessments, completing required Pre-admission Screening and Resident Review (PASRR) for residents with mental illness or intellectual disability, and ensuring blood glucose monitoring was conducted as per physician orders.
Citations (4)
F 0561: The facility failed to honor resident #101's preference for showers, providing only two showers instead of the scheduled six over the review period.
F 0636: The facility failed to complete an accurate comprehensive Minimum Data Set assessment for resident #36 by omitting the diagnosis of Hypothyroidism.
F 0644: The facility failed to complete required PASRR evaluations for 2 of 5 residents with intellectual disability or serious mental illness, residents #76 and #48.
F 0684: The facility failed to ensure blood glucose monitoring was conducted as ordered for resident #358, with no documentation of monitoring found.
Report Facts
Residents reviewed: 34
Scheduled showers: 6
Showers received: 2
Weight loss percentage: 5.6
Blood glucose monitoring frequency: 2
Inspection Report — Oct 7, 2021
Routine
Date: Oct 7, 2021
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments, care planning, activities of daily living, accident prevention, and intravenous therapy in a nursing home facility.
Findings
The facility failed to accurately complete Minimum Data Set assessments for hospice services, develop person-centered care plans for hospice and intravenous antibiotic therapy, provide adequate nail care for a dependent resident, ensure wheelchair anti-tippers were correctly positioned to prevent accidents, and provide timely dressing changes for a midline intravenous catheter.
Citations (5)
F 0641: The facility failed to accurately complete the Minimum Data Set assessment regarding hospice services for 1 of 3 residents reviewed for hospice services.
F 0656: The facility failed to develop a person-centered care plan for hospice services for 1 of 3 residents and for intravenous antibiotic therapy for 1 of 1 resident reviewed.
F 0677: The facility failed to provide nail care for 1 of 4 dependent residents reviewed for activities of daily living.
F 0689: The facility failed to ensure wheelchair anti-tippers were positioned correctly to prevent accidents for 1 of 5 residents reviewed for falls and accident hazards.
F 0694: The facility failed to provide dressing changes for a midline intravenous catheter according to professional standards for 1 of 1 resident reviewed.
Report Facts
Residents reviewed: 35
Residents reviewed for hospice services: 3
Residents reviewed for activities of daily living: 4
Residents reviewed for falls and accident hazards: 5
Residents reviewed for IV catheters: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN MDS Coordinator D | Registered Nurse, MDS Coordinator | Acknowledged inaccurate MDS assessment and lack of hospice care plan |
| RN B | Registered Nurse | Confirmed hospice services and nail care issues |
| ADON | Assistant Director of Nursing | Validated IV catheter presence and nail care scheduling |
| Infection Preventionist | Infection Preventionist | Explained IV dressing change responsibilities and care plan creation |
| CNA G | Certified Nursing Assistant | Reported nail care scheduling and acknowledged missed nail care |
| CNA F | Certified Nursing Assistant | Confirmed nail care was part of ADL care and was not provided on assigned day |
| Interim Director of Nursing | Interim Director of Nursing | Explained nail care provision and supervision |
| Therapy Manager | Therapy Manager | Validated incorrect wheelchair anti-tipper positioning |
| MDS Coordinator RN J | Registered Nurse, MDS Coordinator | Stated importance of timely care plan creation and updating |
| Interim DON | Interim Director of Nursing | Stated hospice care plan should be developed if resident is on hospice |
6 CMS Surveys
CMS Survey — May 14, 2024
May 14, 2024
CMS Survey — Aug 21, 2024
Aug 21, 2024
CMS Survey — Mar 4, 2025
Mar 4, 2025
CMS Survey — Oct 7, 2021
Oct 7, 2021
CMS Survey — Aug 3, 2023
Aug 3, 2023
CMS Survey — Mar 13, 2025
Mar 13, 2025
Loading inspection reports...
