Westminster at Lake Ridge

In the surveyor’s words

From the most serious findings on record at Westminster at Lake Ridge, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 22, 2026

  Based on observations, interviews and facility document review, the facility staff failed to maintain a safe environment for one of thirty-seven residents in the survey sample (Resident #1). Four oxygen cylinders were observed unsecured constituting the identification of immediate jeopardy (IJ) at Level Four, Isolated scope and severity and substandard quality of care. Upon verification of the removal of the IJ, the scope and severity were lowered to Level Two, Isolated. The findings include:On 1/20/26 at 12:46PM, during initial rounds, four oxygen e-tanks were observed stored freestanding in an upright position, not contained in a stand or holder in Resident #1's room on the secured Memory Care Unit. […]

• No harm, potential for more than minimal, widespreadF843Jan 22, 2026

  Based on staff interview and facility documentation review, the facility staff failed to ensure there was a written transfer agreement with a local hospital which had the potential to affect all residents residing on 3 of 3 units. Findings included:On 1/21/2026 at 1:15 p.m. as a part of the extended survey, an interview was conducted with the Administrator who was asked provide evidence of a transfer agreement with the hospital. The Administrator stated he would look for a copy of the agreement. On 1/22/2026 at 9:20 a.m., the Administrator stated he could not find any evidence of a transfer agreement with the hospital. He stated he was sure the facility would have an agreement but could not find it. […]

• No harm, potential for more than minimal, patternF886Jun 23, 2022

  Based on staff interview, and facility documentation review, the facility staff failed to develop a procedure for unvaccinated and vaccinated staff who refuse or are unable to be tested for COVID-19 in accordance with the Centers for Disease Control and Prevention (CDC) guidance. The findings included: There were no COVID positive staff nor Residents present in the facility during the course of the survey, from 6-21-22 through 6-23-22. Staff were observed wearing eye protection and face masks during the survey in accordance with community transmission rates, and according to CDC guidance. Staff were interviewed and asked what the procedure was for those staff who are unable or unwilling to be tested . Two direct care staff members, and one house keeping staff member, were interviewed. […]

• No harm, potential for more than minimal, patternF686Mar 15, 2021

  Based on observation, staff interview, clinical record review, facility documentation review, and in the course of an investigation, the facility staff failed to implement wound treatment orders for 2 residents (Resident #2, Resident #3) in a sample size of 5 residents. The findings included: For Resident #2: 1a) the facility staff failed to ensure wound treatments were in place for an unstageable pressure wound observed on 03/11/2021. 1b) the facility staff failed to perform hand hygiene between glove changes. 1c) and applied santyl directly to a wound with a contaminated cotton-tipped applicator on 03/11/2021 increasing the risk of wound infection. Resident #2, a [AGE] year-old male, was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF607Jun 23, 2022

  Based on facility documentation review and staff interview, the facility staff failed to implement their abuse policy for screening employees for 8 employees (Employee#1, Employee #4, Employee #5, Employee #8, Employee #9, Employee #10, Employee #16, Employee #23) in a sample size of 25 employees. The findings included: On [DATE], the facility staff provided a copy of their policy entitled, Abuse Prevention Program. In Section 2(a), it was documented, Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has (a) been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . […]