Westminster Commons

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Aug 13, 2026

  Based on observations, staff interviews, and review of the Facility Policy, Hand Washing the facility failed to prepare puree foods under sanitary conditions for three of three residents (R) receiving a puree diet. This deficient practice had the potential to cause foodborne illness to residents receiving a puree diet. Findings include:Review of the facility's policy titled, Hand Washing, undated, documented the following Procedure instructions: 1. When to Wash Hands. After handling soiled equipment or utensils. […]

• No harm, potential for more than minimal, widespreadF880Jun 3, 2022

  Based on record review, staff interview, and review of facility policy titled, Infection Prevention and Control Program Overview, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. The facility census was 72 residents. Findings include: A review of the facility policy titled Infection Prevention and Control Program Overview Issued November 28,2016 and last reviewed October 2021 revealed the following (not all inclusive) Goals The goals of the infection prevention program are to: A. Decrease the risk of infection to residents and personnel. B. […]

• No harm, potential for more than minimal, widespreadF881Jun 3, 2022

  Based on record review and staff interview, and review of the facility policy titled, Antibiotic Stewardship, the facility failed to ensure it developed and implemented an Antibiotic Stewardship Program to include antibiotic use protocols and a system to monitor antibiotic use. This had the potential to affect all 72 residents who reside in the facility. Findings include: During a review of the facility policy titled Antibiotic Stewardship Issued November 2016 and last reviewed November 2019 revealed a policy statement: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Standards of Practice: 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. […]

• No harm, potential for more than minimal, widespreadF886Jun 3, 2022

  Based on observations, interviews, record reviews, and facility policy titled, Facility Testing requirements for Staff and Residents. The facility failed to produce evidence of testing of residents and staff for the COVID-19 virus based on recommendations from the Centers of Disease Control (CDC), the Centers for Medicare and Medicaid (CMS) and the level of community transmission rates. The facility did not maintain testing logs or line listing forms for the residents or staff. […]

• No harm, potential for more than minimal, patternF600May 22, 2025

  Based on observation, record review, facility policy review, and resident, resident family, and staff interviews, the facility failed to ensure four of eight residents (Residents (R) 17, 43, 136, and 188) reviewed for abuse out of 46 sampled residents were free from abuse. This had the potential and/or physical harm to the residents. Findings include: Review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 indicated, Residents have the right to be free from abuse, neglect . Protect residents from abuse, neglect .by anyone including but not necessarily limited to: a. facility staff; b. other residents .Develop and implement policies and protocols to prevent and identify: a. […]