Westminster Gardens

FACILITY EVALUATION REPORT

The facility underwent an unannounced Required - 1 year visit. The Licensing Program Analyst observed that infection control practices, physical plant safety, and operational requirements were all compliant with regulations. The report explicitly states that no deficiencies were observed during the visit.

The facility underwent a required unannounced annual inspection. The evaluator noted that the facility staff are using appropriate hygiene and cleaning practices, and all operational areas, including physical plant, are compliant. Overall, the report explicitly states that no deficiencies were observed during the visit.

This report details an investigation into allegations of residents being bullied and staff yelling at residents. The investigation found insufficient evidence to support either allegation, resulting in the findings being marked as 'Unsubstantiated'. No specific deficiencies were cited in this report.

The unannounced Case Management visit observed the delayed egress system and the two exit doors as per the approved Fire Safety Request. The evaluator noted that the delayed egress system was working and all walkways were clear of hazards. No deficiencies were cited during this visit.

The facility underwent a continuation annual inspection, which was conducted using the CARE Tool. The inspector noted that the facility is licensed for 200 residents and has approved plans for Hospice Waiver and Dementia Care. No deficiencies were observed during the visit, and documentation reviewed for medication records and staff files was found to be appropriate.

The inspection noted several areas where resident access was restricted. Specifically, multiple rooms and storage areas in both the Memorial Lodge and Shu Lodge were found to be locked or inaccessible to residents. The report otherwise indicated that the facility was generally well-maintained regarding safety features and supplies.

This report details a Complaint Investigation conducted on August 25, 2022, regarding a complaint received on May 2, 2022. The single allegation reviewed was found to be Unsubstantiated, as the department was unable to obtain evidence to support the claim.