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Deficiency Records for Westminster Commons

A list of the most recent deficiencies for Westminster Commons. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Westminster Commons. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-01-19 2024-03-04 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-01-19 2024-03-04 N
Respond appropriately to all alleged violations. Health 2024-01-19 2024-03-04 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-01-19 2024-03-04 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-01-19 2024-03-04 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2024-01-19 2024-03-04 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-01-19 2024-03-04 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2024-01-19 2024-03-04 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2024-01-19 2024-03-04 N
Ensure medication error rates are not 5 percent or greater. Health 2024-01-19 2024-03-04 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2024-01-19 2024-03-04 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2024-01-19 2024-03-04 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2024-01-19 2024-03-04 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-01-23 2024-03-04 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-01-23 2024-03-04 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-06-03 2022-08-01 Y
Provide and implement an infection prevention and control program. Health 2022-06-03 2022-08-01 Y
Implement a program that monitors antibiotic use. Health 2022-06-03 2022-08-01 Y
Perform COVID19 testing on residents and staff. Health 2022-06-03 2022-08-01 Y
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2018-11-14 2019-02-01 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2018-11-17 2018-12-26 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2018-11-17 2018-12-26 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2018-11-17 2018-12-26 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2018-11-17 2018-12-26 N
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. Health 2018-11-17 2018-12-26 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2018-11-17 2018-12-26 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2018-11-17 2018-12-26 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2018-11-14 2018-12-26 N
Install proper backup exit lighting. Fire Safety 2018-11-14 2018-12-26 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2018-11-14 2018-12-26 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2018-11-14 2018-12-26 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2018-11-14 2018-12-26 N
Install corridor and hallway doors that block smoke. Fire Safety 2018-11-14 2018-12-26 N
Have properly sized and located compartments to protect residents from smoke. Fire Safety 2018-11-14 2018-12-26 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2018-11-14 2018-12-26 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2018-11-14 2018-12-26 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2018-11-14 2018-12-26 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2018-11-14 2018-12-26 N

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