Westminster-Canterbury of Richmond

In the surveyor’s words

From the most serious findings on record at Westminster-Canterbury of Richmond, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF625Mar 25, 2021

  Based on interviews and record reviews, it was determined the facility failed to ensure residents were provided a written notice which specified the duration of the bed-hold policy at the time of transfer to the hospital for one of 25 sampled residents (Resident (R) 33). On 12/29/21, R33 was transferred to the hospital because she developed paralysis and hematuria; however, she was not given the written notice that addressed holding the resident's bed during her absence. Findings include: Review of R33's Physicians Progress Note, dated 12/29/21, located in the resident's EMR under the progress notes tab, revealed the resident was sent to the hospital per her physician's recommendation due to a change in condition. […]

• No harm, potential for more than minimal, widespreadF803Mar 25, 2021

  Based on observations, resident and staff interviews, and review of the facility menus, it was determined the facility failed to prepare menus to include portion sizes to ensure residents received adequate amounts of menu items to meet their nutritional needs. This failed practice had the potential to affect the nutritional status of the 125 residents in the facility. The facility also failed to ensure menus were not repetitive in food items. Review of the menus revealed chicken in some form was on the menu for lunch and dinner daily four of four residents (Resident (R) 12, R68, R19, and R110) who ccomplained about the lack of variety if food options. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF812Mar 25, 2021

  Based on observations, interviews, and review of facility policies, the facility failed to date foods in the refrigerators according to the facility policy. The facility failed to air dry dishes and pans before being stacked and stored. The facility also failed to date food in resident refrigerators located in the nursing lounge on three of three floors. These failed practices had the potential to affect the 125 residents in the facility. Findings include: 1. Labeling and Dating Review of facility's undated policy titled, Proper Labeling and Dating, all items in refrigerators were to have a date sticker on them. […]

• No harm, potential for more than minimal, isolatedF658Oct 30, 2024

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for documentation for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to document assessments, interventions, and vital signs in the clinical record on 10/19/24. A review of R1's nurses' progress notes revealed the following: 10/19/24 19:44 (7:44 p.m.) Resident remains lethargic. BP remains low 88/43. Resident responds to tactile and verbal stimuli. Has declined PO (by mouth) this evening. [Name of attending physician] updated. […]

• No harm, potential for more than minimal, isolatedF842Oct 30, 2024

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete, accurate clinical record for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed maintain a complete, accurate medical record by documenting assessments, interventions, and vital signs in the clinical record on 10/19/24. A review of R1's nurses' progress notes revealed the following: 10/19/24 19:44 (7:44 p.m.) Resident remains lethargic. BP remains low 88/43. Resident responds to tactile and verbal stimuli. Has declined PO (by mouth) this evening. [Name of attending physician] updated. […]