Westminster Village

In the surveyor’s words

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

• Actual harm, isolatedF692Apr 10, 2024

  Based on observation, interview, and record review the facility failed to provide feeding assistance, implement nutritional recommendations, evaluate nutritional supplement intakes, notify the physician of significant weight loss, and ensure significant weight loss was evaluated by a dietitian for two (R5, R21) of two residents reviewed for nutrition in the sample list of 31. These failures resulted in R5 experiencing a severe weight loss of 16.65% (percent) in six months and R21 experiencing a 15.6% severe weight loss in two months. […]

• Actual harm, isolatedF689Mar 26, 2024

  Based on observation, interview, and record review the facility failed to utilize the safest assistive devices for one resident (R1) of three residents reviewed for falls in a sample list of three residents. This failure resulted in (R1) slipping from a sit to stand lift and sustaining a dislocated shoulder requiring closed reduction. Findings Include: 1. R1's Care Plan updated 3/5/24 includes the following diagnoses: Fall, Chronic kidney Disease Type III, Congestive Heart Failure, Muscle Weakness, Difficulty Walking, Unsteadiness on Feet, Abnormal Gait, Lack of Coordination, and Abnormal Postures. […]

• Actual harm, isolatedF689Dec 9, 2021

  Based on observation, interview and record review, the facility failed to provide supervision, after assisting a resident to the bathroom, for one of three residents (R125) reviewed for falls in a sample of 22. This failure resulted in R125 falling, while self-transferring from the toilet, sustaining a left distal femur fracture. Findings include: A Fall Prevention policy dated 5/2021 states, A resident that has been identified as a moderate risk for falls but is at an increased risk for falling if left unattended while on the toilet, will not be left unattended while on the toilet. […]

• Actual harm, isolatedF689Apr 22, 2021

  Based on observation, interview and record review, the facility failed to implement interventions to prevent falls and failed to complete a thorough post fall investigation. These failures affect three of three residents (R1, R2, R3) reviewed for falls in the sample of three. These failures caused R1's fall resulting in R1's sternum fracture, severely comminuted fractures of the jaw, and concussion. These failures also caused R2's fall resulting in a nondisplaced hip fracture. Findings include: 1.) R1's Progress Notes dated [DATE] at 11:16pm document R1 admitted to the facility at 6:10pm with diagnosis of Urinary Tract Infection (UTI) and Age Related Debility. R1's Physical Therapy (PT) Discharge Summary dated [DATE] documents R1 was discharged from Physical Therapy (PT) on [DATE]. […]

• No harm, potential for more than minimal, widespreadF577May 29, 2026

  Based on observation and interview, the facility failed to post notice of the availability of state agency survey results. This failure has the potential to affect all 43 residents in the facility.Findings include:On 5/27/26 at 10:05 a.m., during the resident council meeting, residents stated they were unaware of where the state agency survey results were located.On 5/28/26 at 9:15 a.m., the facility's survey results were in a file bin attached to the wall in a hallway containing staff offices. There was not a notice to designate the location of the survey results files.On 5/28/26 at 10:42 a.m., V1 Administrator confirmed there is no posting alerting residents and/or the public where to locate survey results. […]