Above average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westland House during CMS and state inspections, most recent first.
A resident’s Pantoprazole EC 40 mg order directed the medication to be given daily at 6:00 AM for NSAID-induced gastric ulcer prevention, but staff had been administering it around 9:00 AM instead. The Charged Nurse confirmed the timing mismatch and stated she did not know why the MAR system was set for 9:00 AM rather than the ordered time. The facility’s med admin policy states staff are accountable for giving the right drug at the right time.
Failure to Perform Hand Hygiene After Handling Contaminated Item: During a kitchen observation, a DTR picked up a dry mop from the floor under the three-compartment sink and discarded it in the trash without washing his hands. The DTR confirmed hand hygiene was not done after the task, and the IP stated hand hygiene should be performed after touching anything that touched the floor because of cross contamination. The facility policy required handwashing after handling trash.
Open Garbage Dumpster Lid: The facility failed to keep the garbage dumpster lid closed in the designated waste area. During observation, the garbage receptacle was open, flies were seen around the trash, and the DTR confirmed the lid should be closed so animals do not get in. The ADEVS also verified the garbage receptacle should be closed at all times to prevent pests.
Care plans for two residents were incomplete because required interventions were missing. One resident with a dysphagia diet and moderately impaired cognition had a dysphagia care plan with no intervention listed, and the MDS A and Interim DON confirmed the omission. Another resident with ESRD and multiple skin tears had a wound care plan for several affected areas, but no wound care interventions were documented, which the MDS A and Interim DON also verified.
A survey found that a LTC facility failed to properly use bed rails for 25 residents. The facility did not assess entrapment risks, review risks and benefits with residents, or obtain informed consent. Staff interviews revealed a lack of documentation and understanding of protocols, with side rails used as a standard fall prevention measure without considering individual needs or risks.
The facility failed to properly label and store food items, risking the use of expired food in meal preparation for residents. During an inspection, it was found that produce in the walk-in refrigerator was not labeled with receive or use-by dates, contrary to the facility's food safety policy. A staff member confirmed the absence of required labels, highlighting non-compliance with established guidelines.
The facility failed to issue the Notice of Medicare Non-Coverage (NOMNC) in a timely manner for two residents, potentially affecting their ability to appeal insurance coverage decisions. The NOMNC for one resident was signed a day before Medicare coverage ended, and for another, it was signed on the discharge day, both not meeting the required notice period.
A facility failed to individualize a care plan for a resident, who was observed with side rails in use, by not addressing this in the care plan. The resident's care plans focused on fall risk but did not specifically include side rail use. Interviews with RNs and the DON confirmed the absence of a specific care plan or policy for side rails.
The facility failed to ensure that the foot boards of the beds for two residents were properly locked, resulting in a six-inch gap between the mattress and the foot board. This gap was observed during interviews and posed a potential injury risk if a resident slid down the bed. Staff, including a CNA and the DON, acknowledged the hazard and the importance of securing the foot boards as per the facility's fall mitigation policy.
Medication Not Given at Ordered Time
Penalty
Summary
The facility failed to ensure that Pantoprazole EC 40 mg was administered at the physician-ordered time for one resident. The medication order, entered on 8/27/25, directed that one tablet be given daily at 6:00 AM for prevention of NSAID-induced gastric ulcer. During interview and record review on 9/4/25, the Charged Nurse confirmed the medication had been given around 9:00 AM since 8/28/25 and stated she did not know why the medication was set up in the system for 9:00 AM instead of the ordered 6:00 AM. She also acknowledged that staff are supposed to contact the physician to have the order changed if the resident cannot take the medication at 6:00 AM. The facility policy on medication administration stated that healthcare practitioners are accountable for giving the right patient, right drug, right dose, at the right time, via the right route.
Failure to Perform Hand Hygiene After Handling Contaminated Item
Penalty
Summary
The facility failed to prevent the spread of infections during a kitchen observation when the Dietetic Technician Registered picked up a dry mop from the floor under the three-compartment sink and then threw the mop into the garbage bin without washing his hands. During interview, the DTR confirmed that hand washing was not done after picking up the dry mop and stated that hand washing should be done after every task. The Infection Preventionist stated that hand hygiene should be done after touching anything that touched the floor because of cross contamination. The facility policy titled, Storage Handling, Preparation, Serving (Infection Prevention Policy), stated that food service workers must pay particular attention to handwashing and that hands of food handlers must be washed after handling trash.
Open Garbage Dumpster Lid
Penalty
Summary
The facility failed to ensure the garbage dumpster lid was kept closed in the designated waste area. During a concurrent observation and interview on 9/4/25 at 3:05 p.m. with the Dietetic Technician Registered, two dumpsters were observed in the waste area, one for cardboard and one for garbage, and the garbage receptacle lid was open. The DTR confirmed the garbage dumpster lid was open, noted flies flying around the trash, and stated the practice is for the lid to be closed so no animals get in. During an interview later that day, the Assistant Director of Environmental Services verified the garbage receptacle should be closed all the time to prevent pests. The report also cited the FDA 2022 Food Code and the facility's 2024 policy titled Disposal of Trash, both indicating refuse should be stored in receptacles with tight-fitting lids or covers.
Care plans lacked interventions for dysphagia and wound care
Penalty
Summary
Resident 4 had diagnoses including herpes zoster encephalitis, HTN, AKI, and DM2, and a MDS completed on 8/4/25 showed a BIMS score of 10 out of 15, indicating moderately impaired cognition. The resident was on a dysphagia diet of pureed foods and mildly thick liquids. During interview and record review, MDS A confirmed Resident 4 had a dysphagia care plan, but there was no intervention identified in the plan. The Interim DON also confirmed the care plan had goals but was missing an intervention, and stated the intervention should be specific to the resident. Resident 38 had a diagnosis of ESRD and a MDS completed on 8/28/25 showed a BIMS score of 13 out of 15, indicating intact cognition. During observation, the resident was seen with several skin tears on the lower extremities. During interview and record review, MDS A verified Resident 38 had a care plan for wounds on the right radius, left upper extremities, right knee, and left tibia, but there was no intervention listed for the wound care plan. The Interim DON verified that no intervention was in place for the wound care plan, and the facility policy stated care planning includes assessment, problem identification, goal setting, intervention, and referral.
Improper Use of Bed Rails in LTC Facility
Penalty
Summary
The facility failed to ensure the proper use of bed rails for 25 residents, as observed during a survey. The deficiencies included not assessing the risk of entrapment from side rails before their use, not reviewing the risks and benefits with residents or their representatives, and not obtaining informed consent. Additionally, the facility did not attempt alternative measures before resorting to side rails and failed to secure physician orders for their use. These actions were observed across multiple residents' rooms, where side rails were consistently found in the upright position without proper documentation or consent. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed a lack of understanding and adherence to proper protocols regarding the use of side rails. Staff members admitted that assessments were conducted verbally without documentation, and there was no policy in place for the use of side rails. The staff also believed that physician orders and consent were unnecessary unless the side rails were used as restraints, which contradicts regulatory requirements. The observations and interviews highlighted a systemic issue within the facility, where side rails were used as a standard intervention to prevent falls without considering individual resident needs or potential risks. The lack of documentation, informed consent, and alternative measures put residents at risk of entrapment and serious injury, as noted in the FDA's safety alert regarding bed rail use.
Improper Food Labeling and Storage in Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, which could potentially lead to the use of expired food in meal preparation for residents. During an observation and interview in the walk-in refrigerator, it was noted that three stalks of an unspecified produce and two bunches of cilantro were stored in a clear plastic container without any dates or labels. Additionally, another container held approximately seven green squash, also without labels. A staff member acknowledged that these items were supposed to have a receive date and a use-by date. The facility's policy and procedure on food safety, dated 2019, requires that food be covered, labeled, dated, and used within specified time periods, and stored off the floor. The lack of compliance with these procedures was observed, indicating a failure to adhere to the established guidelines for food safety and storage.
Failure to Timely Issue NOMNC
Penalty
Summary
The facility failed to issue the Notice of Medicare Non-Coverage (NOMNC) in a timely manner for two residents, which could have impacted their ability to file an appeal regarding their insurance coverage. For Resident 80, the NOMNC was signed by the resident one day before the last day of Medicare coverage, which was not in compliance with the requirement to provide the notice at least two calendar days before the end of coverage. The Social Services Designee acknowledged that the NOMNC should have been delivered earlier to allow the resident the opportunity to file an appeal. For Resident 81, the NOMNC was signed on the day of discharge, which was also not compliant with the regulation. The Patient Care Coordinator noted that the facility should have issued the NOMNC with a last covered date that allowed for the required notice period. The facility's failure to adhere to the Centers for Medicare & Medicaid Services (CMS) guidelines for issuing the NOMNC was identified during interviews and record reviews, highlighting a deficiency in the facility's process for notifying residents of their Medicare coverage status.
Failure to Individualize Care Plan for Side Rail Use
Penalty
Summary
The facility failed to ensure that the care plan for a resident was individualized and revised to reflect the resident's current care needs and interventions. During an observation, the resident was seen sitting at the edge of the bed with the two upper side rails in the upright position. The resident's clinical record indicated an admission with a diagnosis of cellulitis of the left hand. However, the care plans did not address the use of side rails, which were instead incorporated into the care plan addressing the risk for falls. Interviews with two registered nurses and the Director of Nursing confirmed that there was no specific care plan or policy for the use of side rails.
Improperly Locked Bed Foot Boards Create Hazard
Penalty
Summary
The facility failed to ensure that the foot boards of the beds for two residents were properly locked, creating a potential hazard. During observations and interviews, it was noted that there was a six-inch gap between the mattress and the foot board in the rooms of two residents. One resident expressed dissatisfaction with the bed, while a physical therapist acknowledged the gap's presence but was unsure of its cause. A registered nurse and a certified nursing assistant later confirmed the gap and adjusted the foot board to eliminate it. Interviews with staff, including a CNA and the Director of Nursing, revealed that the gap could lead to potential injuries if a resident slid down the bed. The facility's policy on fall mitigation emphasized the importance of ensuring bed safety features, such as locking the foot board, to prevent such hazards. Despite these guidelines, the staff did not initially secure the foot boards, leading to the observed deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monterey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monterey Post Acute | 1.8 mi | ★★★★★ | 4 | 0 |
| Cypress Ridge Care Center | 1.9 mi | ★★★★★ | 4 | 0 |
| Carmel Hills Care Center | 2.3 mi | ★★★★★ | 31 | 0 |
| Oceanview Post Acute | 2.8 mi | ★★★★★ | 15 | 0 |
| Canterbury Woods | 2.9 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.