Deficiencies (last 10 years)
Deficiencies (over 10 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 6
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.
Deficiencies (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
Complaint Investigation
Deficiencies: 1
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.
Deficiencies (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
Complaint Investigation
Deficiencies: 2
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.
Deficiencies (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
Complaint
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
State-compiled facility profile showing multiple inspections from 2012 to 2024 with deficiency history and inspection statuses.
Findings
Across all inspections, the facility had a mix of no deficiencies, deficiencies cited, and deficiencies corrected. Several complaint and standard inspections reported deficiencies, but many monitoring inspections found no deficiencies.
Report Facts
Inspections on page: 22
Inspection Report
Routine
Deficiencies: 4
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.
Deficiencies (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
Routine
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
No deficiencies noted during this standard inspection.
Findings
No deficiencies noted during this standard inspection.
Inspection Report
Annual Inspection
Deficiencies: 4
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.
Deficiencies (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
Routine
Deficiencies: 5
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.
Deficiencies (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 |
Inspection Report
Routine
Deficiencies: 8
Date: Jun 9, 2021
Visit Reason
Multiple Class 3 and Class 4 deficiencies related to licensure, resident care, training, food service, extended congregate care, and background screening.
Findings
Multiple Class 3 and Class 4 deficiencies related to licensure, resident care, training, food service, extended congregate care, and background screening.
Deficiencies (8)
Tag A0004 — LICENSURE - REQUIREMENTS
Tag A0032 — RESIDENT CARE - ELOPEMENT STANDARDS
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Tag A0085 — TRAINING - NUTRITION & FOOD SERVICE
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Tag AE206 — ECC - SERVICE PLANS
Tag AE208 — ECC - RECORDS
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Inspection Report
Routine
Deficiencies: 7
Date: Oct 2, 2019
Visit Reason
Multiple Class 3 and Class 4 deficiencies related to admissions, resident care, medication records, emergency environmental control, extended congregate care training, and background screening.
Findings
Multiple Class 3 and Class 4 deficiencies related to admissions, resident care, medication records, emergency environmental control, extended congregate care training, and background screening.
Deficiencies (7)
Tag A0008 — ADMISSIONS - HEALTH ASSESSMENT
Tag A0010 — ADMISSIONS - CONTINUED RESIDENCY
Tag A0025 — RESIDENT CARE - SUPERVISION
Tag A0054 — MEDICATION - RECORDS
Tag A0200 — EMERGENCY ENVIRONMENTAL CONTROL
Tag AE210 — ECC - TRAINING
Tag CZ814 — BACKGROUND SCREENING CLEARINGHOUSE
Inspection Report
Follow-Up
Deficiencies: 5
Date: Aug 23, 2018
Visit Reason
Class 3 deficiencies related to staffing standards, training for staff in-service, assistance with self-administered meds, do not resuscitate orders, and extended congregate care training.
Findings
Class 3 deficiencies related to staffing standards, training for staff in-service, assistance with self-administered meds, do not resuscitate orders, and extended congregate care training.
Deficiencies (5)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Tag AE210 — ECC - TRAINING
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 20, 2017
Visit Reason
Class 3 deficiencies related to staffing standards, assistance with self-administered meds, and do not resuscitate orders training.
Findings
Class 3 deficiencies related to staffing standards, assistance with self-administered meds, and do not resuscitate orders training.
Deficiencies (3)
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0084 — TRAINING - ASSIS SELF-ADMIN MEDS & MED MGMT
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Inspection Report
Routine
Deficiencies: 6
Date: Sep 29, 2015
Visit Reason
Class 3 deficiencies related to medication assistance, staffing standards, first aid and CPR training, food service dietary standards, and extended congregate care health assessment and records.
Findings
Class 3 deficiencies related to medication assistance, staffing standards, first aid and CPR training, food service dietary standards, and extended congregate care health assessment and records.
Deficiencies (6)
Tag A0052 — MEDICATION - ASSISTANCE WITH SELF-ADMIN
Tag A0078 — STAFFING STANDARDS - STAFF
Tag A0083 — TRAINING - FIRST AID AND CPR
Tag A0093 — FOOD SERVICE - DIETARY STANDARDS
Tag AE205 — ECC - HEALTH ASSESSMENT
Tag AE208 — ECC - RECORDS
Inspection Report
Complaint
Deficiencies: 3
Date: Oct 3, 2013
Visit Reason
Class 3 deficiencies related to staff in-service training, HIV/AIDS training, and do not resuscitate orders training.
Findings
Class 3 deficiencies related to staff in-service training, HIV/AIDS training, and do not resuscitate orders training.
Deficiencies (3)
Tag A0081 — TRAINING - STAFF IN-SERVICE
Tag A0082 — TRAINING - HIV/AIDS
Tag A0090 — TRAINING - DO NOT RESUSCITATE ORDERS
Inspection Report
Complaint
Deficiencies: 0
Date: Jul 18, 2012
Visit Reason
No deficiencies noted during this complaint inspection.
Findings
No deficiencies noted during this complaint inspection.
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