Inspection Reports for
Westminster Winter Park

Westminster Winter Park has had 44 inspections with 21 visits citing deficiencies and 9 clean visits. There were 67 deficiencies recorded, none in the most serious classes, and 10 legal actions with fines totaling $8,000.

The facility failed to administer oxygen therapy as ordered for two residents, with oxygen concentrators set at higher or lower flow rates than prescribed. Nursing staff did not consistently check or adjust oxygen flow rates according to physician orders.

The investigation was complaint-driven, focusing on resident rights violations related to bathing preferences, baseline care plan documentation, and care plan participation. The complaints were substantiated with findings.

The facility failed to honor resident #55's bathing preference for showers, instead providing bed baths. Resident #869 did not receive a timely written summary of her baseline care plan within 48 hours of admission. Resident #38 and/or her representative were not invited or involved in care plan meetings as required.

The facility failed to notify physicians and family representatives of changes in condition related to pressure ulcers, failed to provide adequate pressure ulcer care resulting in actual harm, and had insufficient nursing and CNA staffing to meet resident care needs. Medication administration was frequently delayed beyond acceptable timeframes.

The facility failed to honor a resident's full code status by not initiating CPR when the resident was found unresponsive with no vital signs. The failure involved licensed nursing staff disregarding physician orders and resident wishes, leading to the resident's death. Immediate jeopardy was identified and later removed after corrective actions were implemented.

The investigation was complaint-driven, triggered by concerns about meal service practices, care planning for a resident with swallowing difficulties, resident positioning during meals, food safety, garbage disposal, and infection control. The choking incident involving Resident #82 was substantiated, and the facility was found deficient in care planning and other areas.

The facility failed to provide a homelike dining environment by serving meals on trays in an institutional manner, did not develop a comprehensive care plan addressing swallowing problems for a resident who subsequently died from choking, improperly positioned residents during meals, failed to maintain food safety standards including improper food storage and temperature control, did not properly dispose of garbage, and staff failed to perform proper hand hygiene during meal service.

The inspection identified multiple deficiencies including failure to maintain clean and homelike resident rooms, failure to post daily nurse staffing hours timely, presence of expired medication in storage, and food safety issues such as improper refrigeration temperatures, malfunctioning freezer door, unclean ice machines, and a broken pressure gauge on the dishwashing machine.