Life Care Center of Westminster

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure medical gas and vacuum systems have documented maintenance programs.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that sources of ignition are removed from patients receiving respiratory therapy.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Pharmacy Service Deficiencies

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.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Based on a record review, observations, inspection, and interviews, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. The deficient practice affected all smoke compartments. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,80 of 80 residents, and an indeterminable number of staff and vis.. Based on a record review, observations, inspection, and interviews, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,80 of 80 residents, and an indeterminable number of staff and visitors... Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain hazard areas in accordance with NFPA 101, 99, 80, and 58. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,80 of 80 residents, and an indeterminable number of staff and visitors... Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. The deficient practice affected 2 of 9 smoke compartments. The deficient practice could affect all smoke zones,40 of 80 residents, and an indeterminable number of staff and visitors... Based on observation and the maintenance director' s interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. The deficient practice affected 3 of 9 smoke compartments. The deficient practice could affect all smoke zones,60 of 80 residents, and an indeterminable number of staff and visitors... Based on observation during the survey, it was determined that the facility failed to maintain a hazardous area in accordance with NFPA 99. The deficient practice affected 1 of 9 smoke compartments. The deficient practice could affect all smoke zones,20 of 80 residents, and an indeterminable number of staff and visitors. .. *** CITATION TEXT NOT FOUND *** Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a)...

A recertification survey with complaint #CO39096 and Incident #39731 was completed on 4/28/25 to 5/1/25. Ten deficiencies were cited. An Emergency Preparedness survey was conducted from 4/28/25 to 5/1/25. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance for two (#41 and #35) of five residents out of 33 sample residents. Specifically, the f.. Based on observations, record review and interviews, the facility failed to ensure one (#41) of five residents reviewed for pressure injuries out of 33 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing. Resident #41 was admitted on 5/13/24 for long term care. At the tim.. Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%).Specifically, the facility' s medication error rate was 13%, which was four errors out of 29 opportunities for error. Findings include: I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al... Based on observations, record review, and interviews, the facility failed to ensure one (#28) of five residents reviewed for grievances out of 33 sample residents was provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to promptly resolve Resident #28' s grievance regarding care provided by certified nurs.. Based on record review and interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner for one (#15) of five residents out of 33 sample residents.Specifically, the facility failed to ensure the physician documented that he or she reviewed thepharmacist' s identified monthly drug regimen review irregularities .. Based on record review and interviews, the facility failed to ensure prompt action was taken to resolve grievances from a group. Specifically, the facility failed to resolve residents' concerns regarding not enough floor staff to provide care such as showers, call light wait times and no hot water for showers. Findings include:I. Facility policy and proce.. Based on record review and interviews, the facility failed to ensure three (#61, #15 and #28) of five residents reviewed for psychotropic medications out of 33 sample residents were as free from unnecessary medication as possible. Specifically, the facility failed to:-Ensure Resident #15 and Resident #61 had appropriate mood and behavior monitor.. Based on record review and interviews, the facility failed to honor resident choices for two (#53 and #26) of four residents reviewed out of 33 sample residents. Specifically, the facility failed to ensure Resident #53 and Resident #26' s recevied showers consistently according to the resident' s choices and plan of care. Findings include:I. Facility p.. Based on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one (#28) of five residents reviewed for medication management out of 33 sample residents.Specifically, the facility failed to ensure Resident #28 was administered medications per physician' s orders i.. Based on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and reside..

A licensure survey was completed on 4/28/25 to 5/1/25. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure one (#41) of five residents reviewed for pressure injuries out of 26 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing. Resident #41 was admitted on 5/13/24 for long term care. At the time of his admission, the resident was identified as being at risk for developing pressure injuries and he did not have any pressure injuries upon admission. On 12/2/24 the facility documented Resident #41 had a new wound with an open area on his left inner heel measuring 3.0 centimeters (cm) by 0.9 cm. The facility failed to implement preventative measures to protect the resident' s heels after the development of the left heel wound on 12/2/24.On 12/4/24 a nurse progress note indicated Resident #41 had an unstageable pressure wound to his left heel.On 12/10/24 the resident was seen by a wound care physician (WCP) who classified the resident' s left heel wound as an unstageable pressure ulcer.Due to the facility' s failure to implement personalized effective pressure injury interventions to offload and protect the resident' s heels in a timely manner, Resident #41 developed a facility-acquired unstageable pressure injury to his left heel. Findings include:I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, Emily Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019) retrieved on 5/2/25 from https://www.internationalguideline.com/guideline, "Pressure ulcer classification is as follows:"Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, so..

A survey prompted by #CO38150 was conducted on 11/12/24 to 11/13/24. One deficiency was cited. Based on interviews and record reviews, the facility failed to ensure residents had the right to a dignified existence for two (#1 and #3) of three residents out of three sample residents..Specifically, the facility failed to ensure residents' call lights were answered in a timely manner. Findings include:I. Facility policyThe Resident Rights policy and procedure, revised on 9/10/24, was received from the nursing home administrator (NHA) on 11/11/24 at 11:54 a.m. It revealed in pertinent part "At the time of admission and periodically throughout their stay, the facility will inform each resident, orally and in writing, of their rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility."A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident' s individuality. The facility must protect and promote the rights of the resident."The resident has the right to reside and receive services in the facility with reasonable accommodations of resident preferences except when to do so would endanger the realty and safety of the resident or other residents. "The resident has the right to make choices about .. Based on observations, record review and interviews, the facility failed to honor resident choices for three (Resident #1, #2 and #3) of three residents out of four sample residents.Specifically, the facility failed to honor residents' preferences to include beverages, specifically soda, of choice at any time.Findings include:I. Facility policy and procedureThe Resident Rights policy and procedure, revised on 9/10/24, was received from the nursing home administrator (NHA) on 11/11/24 at 11:54 a.m. It revealed in pertinent part "At the time of admission and periodically throughout their stay, the facility will inform each resident, orally and in writing, of their rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility."A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident' s individuality. The facility must protect and promote the rights of the resident."The resident has the right to reside and receive services in the facility with reasonable accommodations of resident preferences except when to do so would endanger the realty and safety of the resident or other residents. "The resident has the right to ..