Westminster Oaks

In the surveyor’s words

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

• Immediate jeopardy, isolatedF610Apr 8, 2021

  Based on interviews and record reviews, the facility failed to investigate incidents of elopement for 2 of 2 residents sampled for elopement (Residents #1 and #2) and failed to ensure corrective actions were carried out for 1 of 2 residents reviewed (Resident #1). The facility's failure to investigate incidents of elopement to determine root cause lead to additional occurrences of elopement and placed 11 other residents identified as risk for elopement at a likelihood of serious injury and death. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated (J). The Immediate Jeopardy began on 2/2/2021. The facility Administrator was notified of the Immediate Jeopardy on 4/7/2021 at 5:15 PM, prior to survey exit on 4/8/2021. […]

• Immediate jeopardy, isolatedF689Apr 8, 2021

  Based on observation, staff interview and record review, the facility failed to ensure 2 of 2 vulnerable residents at risk for elopement (Resident #1 and #2) were not able to exit the building unsupervised (Resident #1 on 2/4/21 and Resident #2 on 2/2/21, 2/15/21, 2/23/21 and 2/28/21). Additionally, on 4/5/21/21, the facility failed to ensure all entry/exit doors were secured to prevent subsequent elopements and that staff were educated on how to respond to elopement alarms which has the potential to effect 11 current residents identified as at risk for elopement. The facility's failure to prevent multiple elopements and eliminate potential hazards placed Residents #1 and #2 and 11 other residents at a likelihood of serious injury and death. […]

• Immediate jeopardy, isolatedF867Apr 8, 2021

  Based on observation, interviews and record reviews, the facility failed to identify and act upon known elopement events for 2 of 2 residents sampled for elopement (Resident #1 and #2) and failed to provide training for staff in response to door alarms and resident elopements. The facility's failure to identify elopement risk as an area of improvement placed Residents #1 and #2 as well as 11 other residents identified at risk for elopement at a likelihood of serious injury and death. The situation resulted in a finding of Immediate Jeopardy at a scope and severity of isolated (J). The Immediate Jeopardy began on 2/2/2021. The facility Administrator was notified on of the Immediate Jeopardy on 4/7/2021 at 5:15 PM, prior to survey exit on 4/8/2021. […]

• No harm, potential for more than minimal, isolatedF656Aug 14, 2025

  Based upon observations, interviews, and record review, the facility failed to implement care plan interventions for safe transfer with a mechanical lift for 1 out of 24 residents reviewed. (Resident #27)The findings include:On 8/13/25 at 08:25 AM, an observation of Resident #27 was conducted. Resident #27 was observed in a mechanical lift sling, suspended midair over the bed. Staff Member B (a Certified Nursing Assistant (CNA)) present in the room, retrieving Resident #27's wheelchair, removing the leg rest that was sitting on wheelchair seat. Staff Member B was interviewed at this time and stated, I'm getting her up now. […]

• No harm, potential for more than minimal, isolatedF657Aug 14, 2025

  Based on observations, interviews and records review, the facility failed to review and revised the care plan to address the needs of 1 of 1 residents reviewed. (Resident #120)The findings include: On 08/12/25 at approximately 10:35 AM, Resident #120 was observed resting in her room with an external heart monitor taped to her upper chest, displaying a red blinking light.On 08/12/25 at approximately 3:00 PM, an interview was conducted with Resident #120. She reported that on 08/11/25, she attended a follow up appointment with her cardiologist, during which an external heart monitor was placed to evaluate her for possible atrial fibrillation. […]