WESTMINSTER OAKS Nursing Home


WESTMINSTER OAKS (CCN: 105854) is a Non profit - Church related facility located in TALLAHASSEE, FL (32308). The facility has an overall rating of 2/5, health inspection rating of 2/5, and a staffing rating of 2/5. It offers 120 certified beds and maintains an average of 113. residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 2.90014 total hours per resident per day. It has been certified since October 1, 1993 and the last listed health inspection was on July 27, 2023, The facility is located in Leon county and provides senior and nursing home care.

WESTMINSTER OAKS Summary


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Provider Name: WESTMINSTER OAKS

Address: 4449 MEANDERING WAY, TALLAHASSEE, FL 32308

Phone: (850) 878-1136

County: Leon (360)

Ownership Type: Non profit - Church related

Certified Beds: 120

Average Residents Per Day: 113. ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: PRESBYTERIAN RETIREMENT COMMUNITIES, INC.

First Approved Date: October 1, 1993

Affiliated Entity: WESTMINSTER COMMUNITIES OF FLORIDA (563)

Retirement Community: Y, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 2 ()

Health Inspection Rating: 2 ()

QM Rating: 4 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 3 ()

Staffing Rating: 2 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.64701, LPN Staff Hours Per Day: 0.4859, RN Staff Hours Per Day: 0.7671, Licensed Staff Hours Per Day: 1.2531

Total Nurse Staff Hours Per Day, per resident: 2.90014

Weekend Nurse Staff Hours: 2.44591, Weekend RN Staff Hours: 0.5163

PT Staff Hours Per Day, per resident: 0.0472

Nurse Staff Turnover: 57.1, Nurse Turnover Note:

RN Turnover: 48.0, RN Turnover Note:

Admin Left Number: , Admin Turnover Note: 6

Case Mix Nurse Aide Hours Per Day, per resident: 2.1317, Case Mix LPN Hours Per Day: 0.6720, Case Mix RN Hours Per Day: 0.3019

Adjusted Nurse Aide Hours Per Day, per resident: 1.57401, Adjusted LPN Hours Per Day: 0.5336, Adjusted RN Hours Per Day: 0.9573

Total Adjusted Nurse Hours Per Day, per resident: 2.94341

Adjusted Weekend Nurse Hours Per Day, per resident: 2.48240

Health Survey Dates and Scores: Cycle 1: 2023-07-27 (Score: 0), Cycle 2: 2022-01-13 (Score: 16), Cycle 3: 2021-01-08 (Score: 220)

Total Weighted Health Score: 42.000

Reported Incidents: 2, Substantiated Complaints: 2

Infection Control Citations: 1

Fines and Penalties: Number of Fines: 0, Total Fines in Dollars: 0.00, Payment Denials Number: 0, Total Penalties Number: 0

Location and GPS: 4449 MEANDERING WAY,TALLAHASSEE,FL,32308 (30.4769, -84.204)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2022-06-13

Type: Health, Deficiency: Ensure staff are vaccinated for COVID-19

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-25

Citation on 2022-07-07

Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-08-05

Citation on 2022-01-13

Type: Health, Deficiency: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-02-13

Citation on 2022-01-13

Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-02-13

Citation on 2021-04-08

Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-05

Citation on 2021-04-08

Type: Health, Deficiency: Respond appropriately to all alleged violations.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-15

Citation on 2021-04-08

Type: Health, Deficiency: Ensure each resident receives an accurate assessment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-05

Citation on 2021-04-08

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-17

Citation on 2021-04-08

Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-17

Citation on 2021-01-08

Type: Health, Deficiency: Allow residents to self-administer drugs if determined clinically appropriate.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-02-08

Citation on 2021-01-08

Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-02-08

Citation on 2021-01-08

Type: Health, Deficiency: Ensure medication error rates are not 5 percent or greater.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-02-08


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-07-26

Type: Fire Safety, Tag: 0345, Version: New

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-09-18

Citation on 2023-07-26

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-09-18

Citation on 2023-07-26

Type: Fire Safety, Tag: 0911, Version: New

Description: Meet requirements for the installation and maintenance of electrical systems.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-09-18

Citation on 2023-07-26

Type: Fire Safety, Tag: 0918, Version: New

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-09-18

Citation on 2021-01-05

Type: Fire Safety, Tag: 0271, Version: New

Description: Have exits that are accessible at all times.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-06

Citation on 2021-01-05

Type: Fire Safety, Tag: 0291, Version: New

Description: Install emergency lighting that can last at least 1 1/2 hours.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-06

Citation on 2021-01-05

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-06

Citation on 2021-01-05

Type: Fire Safety, Tag: 0371, Version: New

Description: Have properly sized and located compartments to protect residents from smoke.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-06

Citation on 2021-01-05

Type: Fire Safety, Tag: 0781, Version: New

Description: Have restrictions on the use of portable space heaters.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-06

Citation on 2021-01-05

Type: Fire Safety, Tag: 0918, Version: New

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

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-06

Citation on 2021-01-05

Type: Fire Safety, Tag: 0921, Version: New

Description: Ensure that testing and maintenance of electrical equipment is performed.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-04-06