Westminster Canterbury Blue Ri

In the surveyor’s words

From the most serious findings on record at Westminster Canterbury Blue Ri, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 15, 2026

  Based on observation, resident, staff, and family interviews, the facility staff failed to ensure safe transfer from bed to wheelchair for one (1) of 24 residents (Resident #7) in the survey sample, which resulted in harm, sustaining a right hip fracture. The findings included: Resident #7 was originally admitted to the facility on [DATE] and most recently transferred to the local hospital on 4/10/26, diagnosed with a hip fracture and readmitted to the nursing facility on 4/15/26. […]

• No harm, potential for more than minimal, patternF686Apr 15, 2026

  Based on observation, resident and staff interviews, and a review of clinical records, the facility staff failed to accurately assess and classify an open wound for 1 of 24 residents (Resident #30) in the survey sample. The findings included: Resident #30 was admitted to the facility on [DATE]. The residents' current diagnoses included a stroke with left hemiplegia. The significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 04/03/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 11 out of 15. This indicated that Resident #30's cognitive abilities for daily decision-making were moderately impaired. […]

• No harm, potential for more than minimal, patternF837Apr 15, 2026

  Based on staff interviews and review of facility documents, the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility to ensure effective systems were in place to assure the quality of life for the residents in the area of foot care and treatment/services to prevent/heal pressure ulcers.The findings included:During the recertification survey completed on 4/15/26 the facility failed to provide podiatry services for Resident #11 and provide treatment and services to prevent and heal pressure ulcers for Resident #30. On 4/15/26 at 4:12 PM an interview was conducted with the Administrator and the Director of Nursing (DON) regarding podiatry services and treatment and services to prevent and heal pressure ulcers. […]

• No harm, potential for more than minimal, patternF865Apr 15, 2026

  Based on staff interviews and review of facility documents, the facility staff failed to adequately identify, keep systems functioning properly, and implement necessary action plans to assure the quality of life for the residents using the Quality Assurance and Performance Improvement (QAPI) committee to identify deficiencies if the area of foot care and treatment/services to prevent/heal pressure ulcers.The findings included:During the recertification survey completed on 4/15/26 the facility failed to provide podiatry services for Resident #11 and provide treatment and services to prevent and heal pressure ulcers for Resident #30. […]

• No harm, potential for more than minimal, patternF908Mar 9, 2023

  Based on observation, facility document review and staff interview, the facility staff failed to ensure proper function of one of two walk-in freezers serving the main kitchen. The findings include: The walk-in freezer in the main kitchen was observed with heavy ice build-up across the ceiling and on the floor with frozen drips noted on the outside of food packaging. Staff reported this frozen condensation build-up had been ongoing for over five months. On 3/7/23 at 11:13 a.m., accompanied by a dining manager (other staff #2) and the registered dietitian (other staff #3), the walk-in freezer in the main kitchen was inspected. Thick, frozen condensation was observed across the entire ceiling. The left ceiling area had heavier ice build-up several inches thick. […]