Westminster Rehabilitation and Wellness Center

In the surveyor’s words

From the most serious findings on record at Westminster Rehabilitation and Wellness Center, in the surveyor’s own words.

• Actual harm, patternF563Feb 4, 2021

  Based on interview, documentation, and video surveillance review, it was determined the facility failed to initiate the process to allow indoor visitation of family members to residents of the facility when the opportunity following the facility's removal from their COVID-19 outbreak status. The facility did allow outside visitors, unrelated to business with the facility or residents, into the facility for a vaccination clinic. Residents watched the visitors from their rooms and emotionally expressed their sadness as they were not allowed to have their own family come into the facility for visits over the past year. […]

• Actual harm, isolatedF600Aug 14, 2025

  Based on observation, medical record review, facility documentation review and interview, it was determined the facility staff failed to prevent intimidation of a resident after the resident alleged sexual abuse resulting in psychosocial harm (Resident #5). This was evident for 1 of 4 residents reviewed for abuse during a complaint survey.The findings include: Review of facility reported incident 326592 was conducted on 8/12/25 related to Resident #5 allegation of sexual abuse by Staff #4 on 6/4/25.Review of Resident #5's medical record on 8/12/25 revealed the facility staff assessed the Resident on 6/13/25 to have a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating the Resident's cognitive function was intact.Review of the facility reported incident documentation… […]

• Actual harm, isolatedF689Sep 22, 2021

  Based on record review, observation, and staff interview, it was determined that the facility staff failed to put measures in place to safely provide care for a resident by failing to ensure that specialty bed mattresses were properly secured on bed frames and failing to follow the specified number of staff support needed when providing care for residents. This resulted in the resident falling out of the bed and sustaining a fractured shoulder. This was found to be true for 1 of 5 (Resident #5) residents reviewed for accident hazards during the survey. The findings include: A care plan is a guide that addresses the needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. […]

• No harm, potential for more than minimal, widespreadF802Apr 18, 2024

  Based on interview and record review it was determined the facility failed to ensure the kitchen maintained adequate staffing levels. This deficient practice affects all residents. The findings include: On 4/1/24 at 12:16 PM observed Staff #15 working in the kitchen wearing a name tag indicating their job title was maintenance. At this time, the surveyor conducted an interview and inquired as to their role within the facility. Staff #15 reported they had performed different positions including in maintenance, social work, other roles with the exception of nursing, and now in the kitchen as of two weeks ago, they were a culinary aide. […]

• No harm, potential for more than minimal, widespreadF812Apr 18, 2024

  Based on observations of the facility's kitchen, review of kitchen records and interviews of dietary staff, it was determined that the facility failed to: 1.) ensure the monitoring and oversight of food temperatures in accordance with professional standards for food service safety, 2.) ensure sanitary practices were followed in accordance with professional standards for food service safety, 3.) ensure food was stored in accordance with professional standards for food service safety, 4.) ensure the dishwasher reached adequate temperature according to the manufacturer's guideline and 5.) ensure the food supply order was adequate to support the needs of facility residents. […]