Westminster Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Westminster Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Jan 12, 2024

  Based on review of facility policy, interview and record review, the facility failed to accurately notify the physician of all pertinent information with regards to a significant medication error. Specifically, on [DATE], the facility reported to the Medical Director that Resident (R)1 received twice the dosage of insulin when R1 actually received ten times the dosage of insulin. Furthermore, the facility failed to notify the Medical Director of changes in blood sugar for a two-hour period. On [DATE] at approximately 3:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. […]

• Immediate jeopardy, isolatedF760Jan 12, 2024

  Based on review of facility policy, interview and record review, the facility failed to protect 1 of 4 residents from significant medication errors. Specifically, on [DATE] at 1:19 PM, Licensed Practical Nurse (LPN)1 administered 80 units of insulin to Resident (R)1 when he was supposed to receive 8 units. This failure placed R1 at risk for serious harm and/or death due low blood sugars that could potentially cause seizures, hypoglycemic coma, or death. On [DATE] at approximately 3:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. […]

• No harm, potential for more than minimal, widespreadF812Feb 25, 2026

  Based on observation, interview, and facility policy review, the facility failed to ensure raw meat was stored properly in the walk-in refrigerator. This deficient practice had the potential to affect all 6 residents who currently resided in the facility.Findings included:Review of the facility policy titled, Food and Supply Storage, revised 01/2026, indicated, Separate cooked and raw foods. Store ready-to-eat (including pasteurized eggs) and cooked food above raw food. If raw animal foods are stored on the same rack, store them in the following order from top of the rack to the bottom of the rack: raw shell eggs, fish, whole cuts of beef, pork, ground meat and poultry.During a concurrent interview and observation of the walk-in refrigerator in the kitchen on 02/23/26 at 10:28 AM with the… […]

• No harm, potential for more than minimal, isolatedF628Feb 25, 2026

  Based on interview, record review, and facility policy review, the facility failed to ensure transfer and discharge notifications were sent to a representative of the State Long Term Care (LTC) Ombudsman for 2 (Resident (R)6 and R8) of 2 sampled closed records reviewed. Findings included: A facility policy titled, Transfer or Discharge Notices, revised 03/2025, indicated, 3. The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman. 4. Notice of the State LTC Ombudsman will occur at the same time as the notice of discharge is provided to the resident and resident representative. 1. A Resident Face Sheet revealed the facility admitted R8 on 11/06/25. […]

• No harm, potential for more than minimal, isolatedF759Feb 25, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure their medication error rate was not greater than 5 percent (%). There were 2 errors out of 29 opportunities, which resulted in a medication error rate of 6.9% for 2 (Resident (R)9 and R11) of 3 residents observed for medication administration. Findings included:A facility policy titled, Administering Medications, revised 04/2019, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame.1. A Resident Face Sheet indicated the facility admitted R9 on 12/01/25. […]