Westminster Towers

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578Aug 19, 2026

  Based on interview, and record review, the facility failed to honor a resident's documented wishes for Do Not Resuscitate (DNR) status, as elected by the resident's healthcare surrogate, by failing to ensure the resident's executed Florida Do Not Resuscitate Order (DNRO) was readily accessible and available during a medical emergency for 1 of 10 residents reviewed for advance directives, (#1), of a total sample of 10 residents. This failure resulted in resident #1 receiving cardiopulmonary resuscitation (CPR) efforts contrary to the resident's documented wish for a natural and dignified death.On [DATE] at approximately 8:11 PM, resident #1 had a change in condition related to low blood pressure. […]

• Immediate jeopardy, isolatedF678Mar 4, 2025

  Based on interview, and record review, licensed nurses failed to follow the facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) related to verification of code status in an emergency for 1 of 13 residents reviewed for advance directives, (#1). On [DATE] at approximately 7:00 PM, resident #1 was observed unresponsive in her bed. Registered Nurse (RN) A took her vitals and notified RN C resident #1 had passed away. RN A failed to verify resident #1's code status and failed to provide CPR per her wishes. Emergency Medical Services was never called. The facility failed to honor the resident's wish to be resuscitated and the physician order for Full Code status. […]

• No harm, potential for more than minimal, patternF684Mar 13, 2025

  Based on interview, and record review, the facility failed to follow physician orders and ensure the comprehensive care plan was implemented for 1 of 5 residents reviewed for unnecessary medications and medication regimen, of a total sample of 34 residents, (#43). Findings: Review of resident #43's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from a short-term, acute hospital on 1/13/25. Her diagnoses included atrial fibrillation, hypertension (HTN), type 2 diabetes, and stroke. Review of resident #43's comprehensive care plan with a cardiac focus revised on 3/12/25 revealed potential for altered cardiovascular status. The interventions included, Administer cardiac medications as ordered . […]

• No harm, potential for more than minimal, isolatedF554Mar 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents' self-administration of medication for 2 of 2 residents reviewed for self-administration of medications, of a total sample of 33 residents, (#57, and #83). 1. Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including drug-induced secondary Parkinsonism, bipolar disorder, hypertensive heart disease, and dementia. A review of the Minimum Data Set (MDS) quarterly assessment with an assessment reference date of 12/23/24, revealed resident #57 had a Brief Interview for Mental Status (BIMS) score of 13/15, indicating he was cognitively intact. On 3/10/25 at 1:58 PM, resident #57 was sitting on the right side of his bed. […]

• No harm, potential for more than minimal, isolatedF655Mar 13, 2025

  Based on interview, and record review, the facility failed to ensure a written summary of the baseline care plan was provided to 1 of 2 residents reviewed for care plans, (#390); and failed to provide a written summary of the baseline care plan within the required time frame for 1 of 2 residents reviewed for care plans, (#546), of a total sample of 34 residents. Findings: 1. Resident #390, a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included right ankle osteomyelitis, asthma, generalized anxiety disorder, and open wound, right foot. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was intact, with a Brief Interview For Mental Status (BIMS) score of 15 of 15. […]