Westminster Rehabilitation And Wellness Center
Westminster Rehabilitation and Wellness Center in WESTMINSTER, MD — inspection on August 14, 2025.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During interview with Resident #6 on 8/12/25 at 11:22 AM, the Resident stated he/she is missing 4 pairs of sweatpants: 1 blue, 1 black and 2 grey.
The Resident stated he/she has told the facility staff, and they had not done anything about it.
During interview with the Director of Nursing (DON) on 8/13/25 at 8:05 AM, the DON was asked if he/she knew about Resident #6 missing sweatpants.
The DON stated yes the Resident came to me about a month ago and I filled out a grievance.
The DON was asked what the process is after she fills out grievance.
The DON stated she gives the grievance to the Social Worker to follow-up on.
The DON was asked at that time to receive a copy of the grievance.
Review of the Grievance Form revealed on 6/27/25 the DON wrote under Initiation of grievance/Description of grievance: Resident #6 was missing 2 grey, 1 blue, 1 black sweatpants.
Missing for 5 days and checked roommate's clothes and not there.
The next section is Facility Follow up on 7/9/25 by the EVS Director that stated: we found his/her grey pants, no other clothes were found in the laundry. We will keep looking for his/her clothes.
Some clothes found, some still missing.
The next section on form is Resolution of Grievance which was blank.
Review of the facility's Resident Grievance Policy revealed it stated: Grievances will be resolved in a reasonable time frame, generally within 5 business days, consistent with the type of grievance.
During interview with the Administrator on 8/13/25 at 10:30 AM, the Administrator confirmed the grievance for Resident #6 had not been resolved and the facility was working on a process to ensure residents' grievances are resolved.
During interview with the Social Worker on 8/14/25 at 9:00 AM, the Social Worker was asked what her role is in the grievance process.
The Social Worker states she holds the grievance book, collects the grievance, gives to the appropriate person that would handle the grievance and then once they resolve the grievance she places back in the grievance binder.
The Social Worker stated residents' missing items concerns go to the Administrator.
The Director of Nursing on 8/14/25 at 9:30 AM provided the Surveyor with a copy of the facility order on 8/14/25 for four pair of sweatpants for Resident #6.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
215094 08/14/2025
Westminster Rehabilitation and Wellness Center 1234 Washington Road Westminster, MD 21157
Interview with DON on 8/14/25 at 10:00 AM confirmed the intimidation of Resident #5 by Staff #7
an allegation of sexual abuse on 6/4/25 resulting in psychosocial harm to Resident #5.
The DON
care.
215094 08/14/2025
Westminster Rehabilitation and Wellness Center 1234 Washington Road Westminster, MD 21157
Review of the facility's investigation revealed a written statement from the Director of Nursing (DON) that documented Resident #2 thought that it happened the previous night as the resident was up late watching TV in the dining room, however there was not an exact time.
The facility investigation revealed that (5) staff members worked the night shift, 11:00 PM to 7:00 AM, and (8) staff members worked the evening shift, 3:00 PM to 11:00 PM.
There were written statements from (4) of the (5) night shift staff, however only (3) of the (8) evening shift staff were interviewed or had written statements.
There were no interviews or statements provided from the 6/2/25 day shift staff. On 8/13/25 at 9:12 AM an interview was conducted with the DON.
The DON stated that she did the investigation.
The DON stated that the resident came to her office to report the missing money.
The DON stated that the resident said someone in the middle of the night had broken into the bedside drawer and money was missing.
The DON stated the resident's account of the story changed and was inconsistent.
The nursing schedule was reviewed with the DON at that time, and the DON was asked if the resident stated it happened at night and the resident was down watching tv, why wasn't the evening shift staff interviewed about the nightstand drawer.
The DON stated that she should have gotten statements from that staff as well and confirmed that the investigation was not complete.
215094 08/14/2025
Westminster Rehabilitation and Wellness Center 1234 Washington Road Westminster, MD 21157
Review of the audit details revealed the medication was ordered on 7/17/25, however was not dispensed to the facility until 7/20/25. LPN #13 was asked how she was able to give the drops to Resident #1 when the drops had not been received at the facility until 7/20/25. LPN #13 stated that she could not remember, she could have documented that she gave the drops in error. On 8/13/25 at 12:34 PM an interview was conducted with the Director of Nursing (DON).
The July 2025 MAR was reviewed with the DON and the progress notes along with the medication audit sheet.
The DON stated, so 3 nurses signed off that the drops were given and they were not yet delivered to the building.
The DON confirmed the findings.On 8/13/25 at 1:51 PM an interview was conducted with the Nursing Home Administrator (NHA).
The NHA stated she was made aware of the concern from the DON, and she acknowledged the concern.
215094 08/14/2025
Westminster Rehabilitation and Wellness Center 1234 Washington Road Westminster, MD 21157
Review of Resident #4's medical record on [DATE] revealed the Resident was admitted to the facility in [DATE] with a diagnosis of chronic pain due to trauma.
Review of the Resident's physician orders on admission revealed the Resident was ordered Oxycodone 15 mg every 4 hours as needed for pain.
Further review of the Resident's medical record revealed the Resident was followed by the Physical Medicine and Rehabilitation Nurse Practitioner (Staff #15) for pain management.
Review of Staff #15's medication orders revealed Staff #15 decreased the Oxycodone to 10 mg every 4 hours as needed for pain on [DATE]. On [DATE] Staff #15 decreased the Oxycodone to 5 mg every 6 hours as needed for pain for 21 days.
Review of Staff #15's [DATE] progress note revealed it stated: Plan at this time is keep the patient on his/her extended release morphine sulfate 15 mg twice daily and keep his/her as needed Oxycodone 5 mg at every 6 (hours).
Review of Resident #4's physician orders revealed the Oxycodone was discontinued on [DATE] since the order on [DATE] expired after 21 days.
Review of Resident #4's [DATE] Medication Administration Record revealed the Resident had not taken the as needed Oxycodone since [DATE].
Review of Staff #15's [DATE] progress note revealed it stated: Patient not currently on services and is only being seen for pain management.
Currently taking Morphine ER (extended release) 15 mg 2 times a day.
His/her as needed oxycodone was discontinued for unknown reasons.
Patient states today that he/she is in pain in his/her lower extremities and that the as needed medication helped control this pain which he/she is no longer receiving.
Review of Resident #4's physician orders revealed the Oxycodone was reordered on [DATE] for 5 mg every 8 hours as needed for pain.
During interview with Resident #4 on [DATE] at 7:45 AM, the Resident was asked if his/her pain is under control and is he/she receiving his/her pain medication as he/she would like.
The Resident stated yes he/she has no issues with his/her pain medication.
The Resident was asked if he/she could remember in [DATE] when his/her Oxycodone was discontinued and he/she put in a complaint with the Office of Health Care Quality.
The Resident stated no.
During interview with Staff #15 on [DATE] at 8:50 AM, Staff #15 stated he shouldn't have put Resident #4's [DATE] Oxycodone order for 21 days and that was an error.
Staff #15 also stated he should have ordered Oxycodone indefinitely until he had reevaluated the Resident.
Interview with the Director of Nursing on [DATE] at 10:00 AM confirmed Staff #15 failed to review Resident #4's medication orders on [DATE].
215094 08/14/2025
Westminster Rehabilitation and Wellness Center 1234 Washington Road Westminster, MD 21157
services of a licensed pharmacist.
physician ordered medications timely to meet the needs of the residents.
This was evident for 1 (#1)
include:On 8/12/25 at 11:34 AM a review of Resident #1's medical record revealed Resident #1 was admitted to the facility in May 2024 with diagnoses that included, but were not limited to, cerebral infarction with hemiplegia and hemiparesis, aphasia, generalized anxiety disorder, bipolar disorder, and major depressive disorder.Review of a 7/17/25 at 15:20 (3:20 PM) SBAR (change in condition) note documented that Resident #1's left eye was noted with redness, like a blood vessel had broken.
A new order was given to start the resident on an eye drop, Polyethylene glycol.A 7/17/25 at 21:09 (9:09 PM) eMar (electronic Medication Administration Record note) documented, Polyethyl Glycol-Propyl Glycol Gel 0.4-0.3%; Instill 1 drop in left eye two times a day for protection for bloodshot/dry OS (left eye) until 7/27/22; new medication order.
Waiting pharmacy delivery.A 7/19/25 at 22:31 (10:30 PM) eMar note documented, OTC (over the counter) form faxed to pharmacy.
Waiting delivery.A 7/20/25 at 5:54 AM nurse's note documented a note about the Polyethyl Glycol that stated, redness noted left eye sclera.
Waiting delivery.On 8/13/25 at 12:23 PM an interview was conducted with the Director of Nursing (DON), and she was asked if the facility had issues with the pharmacy and timely medication delivery.
The DON stated, the pharmacy is awful, and we have had to escalate the issues to corporate.
The DON stated, there are weekends when I am at home, and I have gone back and forth with the pharmacy to get new patient meds in here timely.
The DON stated that they were in the process of switching pharmacy providers next month.On 8/13/25 at 1:30 PM an interview was conducted with Registered Nurse (RN) #10 who stated they do have an issue with the pharmacy delivering medications timely and there are times when she has to repeatedly call the pharmacy to ask where the medication is and then will have to order the medication STAT (immediately) because the resident really needed the medication.On 8/13/25 at 1:51 PM an interview was conducted with the Nursing Home Administrator (NHA).
The NHA was informed of the concern with timely delivery of medications to the facility and she stated that the DON had made her aware.
215094 08/14/2025
Westminster Rehabilitation and Wellness Center 1234 Washington Road Westminster, MD 21157
Review of the audit details revealed the medication was ordered on 7/17/25, however was not dispensed to the facility until 7/20/25. LPN #13 was asked how she was able to give the drops to Resident #1 when the drops had not been received at the facility until 7/20/25. LPN #13 stated that she could not remember, she could have documented that she gave the drops in error. On 8/13/25 at 12:34 PM an interview was conducted with the Director of Nursing (DON).
The July 2025 MAR was reviewed with the DON and the progress notes along with the medication audit sheet.
The DON stated, so 3 nurses signed off that the drops were given and they were not yet delivered to the building.
The DON confirmed the findings.On 8/13/25 at 1:51 PM an interview was conducted with the Nursing Home Administrator (NHA).
The NHA stated she was made aware of the concern from the DON, and she acknowledged the concern.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.