The Arbour at Westminster Manor

In the surveyor’s words

From the most serious findings on record at The Arbour at Westminster Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 25, 2024

  Based on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to be free from abuse for one resident (Resident #44) of six residents reviewed for freedom from abuse. The facility failed to protect Resident #44 from an aggressive family member with suspected history of abuse. On 08/03/2024 at about 6:30pm, during the dinner, the family member shouted at Resident #44 and forcefully fed her against her will by putting the spoon with food in her mouth, as witnessed by staff members. On 09/24/24 at 4:36 PM an Immediate Jeopardy (IJ) was identified. […]

• No harm, potential for more than minimal, patternF812Dec 3, 2025

  Based on observation, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to seal the food in the freezer. The facility failed to ensure that items were labeled and dated in the freezer. These failures could place residents at risk for consuming contaminated food and developing foodborne illnesses. An observation made on 12/01/2025 at 9:00 AM, of the walk-in freezer revealed food boxes stored on top of crates, unlabeled unidentified food items, and there was food opened in a bag that was not sealed, and the food was exposed to the air. […]

• No harm, potential for more than minimal, patternF880Jul 21, 2023

  Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 wings (East wing) on the second floor of the facility reviewed for infection control, in that: 1. Laundry staff C did not cover Resident's cleaned clothing on the laundry cart while bringing the clothing back to the residents. Laundry staff C did not sanitize her hands between residents' room. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1 . Observation on 07/18/2023 at 1:12 p.m. […]

• No harm, potential for more than minimal, isolatedF641Dec 3, 2025

  Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 residents (Resident #25) reviewed for accuracy of assessments. The facility failed to ensure Resident #25's MDS assessments date 10/01/2025 reflected his contractures on both his hands. This failure could place residents at risk of inadequate care due to an inaccurate MDS assessment. Findings include:Record review of Resident #25's face sheet, dated 12/02/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF558Sep 25, 2024

  Based on observation, interview and record review, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodation of the resident's needs and preferences for 1 of 8 residents (Resident #59) reviewed for accommodation of needs. The facility failed to ensure Resident #59's call light button was within her reach to call for nursing assistance. This failure placed residents at risk of having their needs gone unmet. Findings included: Record review or Resident #59's AR, dated 9/10/2024, reflected a [AGE] year-old female, born on 03/05/1933, who admitted to the facility on [DATE]. […]