Westminster Village Health

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 8, 2025

  Based on observation, interview, record review, and review of other facility documentation it was determined that for one (R1) out of four residents sampled for wandering and elopement the facility failed to ensure adequate supervision to prevent R1 from eloping putting the resident at serious immediate jeopardy and risk of a serious adverse outcome. R1, a resident that was confused was able to elope from the facility on 9/27/25 by climbing out of the window in R1's room. R1 walked across the facility's back parking lot and then proceeded to walk across a busy roadway to an area where there was a raised curb, a sloped hill with trees, shrubs and brush. R1 was missing for seven minutes. An immediate jeopardy (IJ) was identified starting on 9/27/25. […]

• Immediate jeopardy, isolatedF600Nov 1, 2023

  Based on observation, interview and record review, it was determined that for three (R71, R68 and R43) out of six residents reviewed for abuse, the facility failed to ensure that R71, R68 and R43 were free of sexual abuse by R16, a resident with a history of sexually inappropriate behavior. The facility's failure to monitor R16 allowed the sexual abuse of R71 on 9/14/22, R68 on 11/16/22 and R43 on 12/16/22. An Immediate Jeopardy (IJ) was identified starting 9/14/22. Due to the facility's corrective measures following the last incident, this is being cited as immediate jeopardy, past non-compliance with an abatement date of 12/16/22. […]

• Actual harm, isolatedF689Dec 20, 2021

  Based on record review, interview, observation and review of other facility documentation, it was determined, for one (R19) out of four residents sampled for accidents, that the facility failed to ensure the resident received adequate supervision and fall prevention measures appropriate for a resident with severe cognitive impairment. R19's fall on 9/18/21 resulted in harm when R19 broke his neck, resulting in pain and limited use of his right arm affecting the ability to feed himself. Findings include: The facility policy entitled Falls Management (revised 8/10/21) identified that interventions are to be re-evaluated after each fall. When changes are added to the care plan involving new interventions these new interventions need to be dated. […]

• No harm, potential for more than minimal, widespreadF919Dec 16, 2025

  Based on observation, interview and review of other facility documentation it was determined that the facility failed to have a functioning call bell system. Findings include: 12/9/25 10:57 AM room [ROOM NUMBER] - During initial observations the surveyor discovered that the call bell was not functioning. There was no sound and the light outside of the doorway was not lit after the call bell was pressed. E25 (LPN) confirmed the finding.12/9/25 12:05 PM room [ROOM NUMBER] - During initial observations the surveyor discovered that the call bell was not functioning. E26 (CNA) confirmed the finding. E26 then notified E25 (LPN) who immediately placed a call to the maintenance department. […]

• No harm, potential for more than minimal, widespreadF756Nov 1, 2023

  Based on interview and record review, it has been determined that for two (R10 and R21) out of five residents sampled for unnecessary medication review, the facility failed to ensure the physician reviewed and signed the consultant pharmacist communication. In addition, the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Reviews) that included time frames for different steps in the MRR process. Findings include: 1. Review of R10's clinical record revealed: 6/28/22 - R10 was admitted to the facility with diagnosis of depression, vascular dementia, psychosis, and repeated falls. 5/17/23 - A consultant pharmacist communication to the physician documented . 1. Per CMS guidelines, all PRN (as needed) psychotropic medications require a stop date . 1. […]