Westminster Rehab: Missing Clothes Grievance Unresolved - MD
The resident, identified in inspection records only as Resident 6, has lived at the facility since July 2022. When inspectors interviewed him on August 12, he described the missing clothes precisely: one blue pair, one black pair, two grey. He scored 14 out of 15 on a cognitive assessment administered days earlier, meaning his account was not in question. He told inspectors he had reported the problem to staff. Nothing had happened.
The paper trail confirmed it.
The Director of Nursing had filled out a grievance form on June 27, noting the resident was missing two grey, one blue, and one black sweatpants, and that the clothes had been gone for five days. Staff had already checked the roommate's belongings. Nothing turned up there either. The grievance then went to the social worker, who passed it to the EVS Director, the facility's environmental services lead.
On July 9, the EVS Director wrote in the follow-up section that one grey pair had been found in the laundry. The other three pairs had not. "We will keep looking for his/her clothes," the entry read. "Some clothes found, some still missing."
That was the last entry. The resolution section beneath it was left blank.
The facility's own grievance policy states that complaints will be resolved within five business days. By the time inspectors sat down with the Director of Nursing on the morning of August 13, more than six weeks had passed since the grievance was filed, and more than a month since the EVS Director's partial update.
The Director of Nursing told inspectors she had known about the missing sweatpants because the resident had come to her directly about a month before the inspection. She said her role was to fill out the grievance form and hand it to the social worker. The social worker told inspectors her role was to collect grievances, route them to whoever should handle them, and file the resolved ones back in the binder. She said missing items go to the administrator.
The administrator, interviewed the same morning, confirmed the grievance had not been resolved and said the facility was working on a process to make sure resident grievances get closed out.
Nobody had replaced the sweatpants.
On August 14, the final day of the inspection, the Director of Nursing handed the inspector a copy of a facility order placed that morning for four pairs of sweatpants for Resident 6.
The timing was not lost on inspectors. The order came after six weeks of inaction, on the last day of a complaint survey triggered by the missing clothes.
Inspectors cited the facility for failing to maintain an effective grievance system, rating the violation as causing minimal harm or potential for actual harm. It affected one of three residents reviewed for grievances during the complaint survey.
The violation is narrow in scope. The harm documented is not physical. But the inspection record draws a clear picture of a grievance system that moved a complaint through three staff members over nearly seven weeks, produced one partial update, and then stopped. A cognitively intact resident who knew exactly what he was missing and had asked for help repeatedly was still waiting when investigators walked through the door.
The facility's own form had a space for resolution. It sat empty for forty-seven days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westminster Rehabilitation and Wellness Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Westminster Rehabilitation and Wellness Center in WESTMINSTER, MD was cited for violations during a health inspection on August 14, 2025.
The resident, identified in inspection records only as Resident 6, has lived at the facility since July 2022.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.