Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Western Hills Health Care Center during CMS and state inspections, most recent first.
Broken Heated Plate Dispenser Left Out of Service: The main kitchen’s heated plate dispenser/lowerator was found unplugged, cold, and nonfunctional, with staff using it only to hold plates during trayline service. A cook reported the unit had been broken for over six months and had sparked fire when plugged in, while the DM and NHA confirmed the equipment was damaged beyond repair and that no interim protocol was in place.
Failure to complete annual CNA performance reviews and related in-service education: the facility did not provide timely performance evaluations for three CNAs reviewed, could not produce one review, and one review lacked a completion date. One CNA’s evaluation identified deficiencies in communication and punctuality, but there was no documentation of education tied to those findings. Interviews showed the NHA, regional VP, and staff development coordinator described differing responsibilities for completing reviews and follow-up training.
Infection Control Failures in Room Cleaning and Disinfection: Housekeeping staff were observed cleaning resident room sinks, toilets, bedside tables, and high-touch surfaces in a manner that did not follow hygienic sequence or the Virex dwell time. Staff used the same cloth across cleaner and dirtier areas, wiped a toilet seat after cleaning the bowl rim, and removed disinfectant before the required wet contact time. Interviews showed inconsistent understanding of proper disinfection and high-touch surface cleaning.
Failure to provide clean clothing and launder soiled laundry for a resident with COPD, chronic respiratory failure, and moderate cognitive impairment. The resident was observed wearing the same soiled clothes on multiple days, reported he had been asking staff to send his laundry out, and said he had been without clean underwear. Staff stated laundry was collected daily, but there was no system to track whether residents consistently had clean clothing available.
Failure to promptly resolve grievances for missing personal property. Two residents reported missing items, including hearing aids and sentimental Christmas ornaments, but the facility did not consistently document, investigate, or follow up on the concerns. One resident had severe cognitive impairment and the other was cognitively intact; staff and the NHA acknowledged gaps in grievance reporting, and one grievance was considered resolved without the resident representative’s approval.
Failure to Investigate Missing Resident Property: The facility did not thoroughly investigate allegations that two residents’ personal property went missing. One resident with severe cognitive impairment had hearing aids, a charger, and a storage case disappear, while another cognitively intact resident reported missing boxes of sentimental Christmas ornaments. Staff and the SSD acknowledged the items were missing, but there was no documented investigation into whether the property was misplaced or stolen, and the NHA did not follow up on the second resident’s report.
A resident with a recent tibia fracture, osteoporosis, muscle weakness, cerebral palsy, and impaired lower-extremity movement was observed using a gait belt around her waist and wheelchair to prevent sliding out. Staff said the resident could remove the belt herself and that it was being used for positioning/safety, but the Kardex and baseline care plan did not document the belt or clarify the resident’s ability to remove it. Rehab staff also stated the resident had recently started using the personal wheelchair and belt and had not yet been assessed for this device use.
Failure to provide personalized activity programming: A resident with vascular dementia, depression, and severe cognitive impairment had documented preferences for music, movies, reading, and animal-related activities, but records showed limited participation in those preferred activities and no documented refusals for several missed opportunities. Observations found the resident asleep or sitting alone with little meaningful engagement, and staff did not assist her to a scheduled radio activity. The resident’s representative reported the resident was often alone without the stuffed animals and busy boxes provided and wanted more social involvement.
Failure to provide hearing assistive devices for a resident with cognitive impairment and a hearing deficit. The resident’s hearing aids were missing for weeks, no alternative communication device was available, and staff reported difficulty communicating with the resident, who was observed repeatedly indicating she could not hear and asking others to repeat themselves.
Two residents receiving continuous oxygen therapy did not have their concentrators set to the physician-ordered flow rates. One resident with COPD, pneumonia, and respiratory failure was ordered 4 LPM via NC but was observed at 3.5 LPM, while another resident with COPD exacerbation and chronic respiratory failure was ordered 3 LPM via NC but was observed at 2.5 LPM on multiple occasions. Staff interviews confirmed the ordered settings and the observed discrepancies.
Broken Heated Plate Dispenser Left Out of Service
Penalty
Summary
The facility failed to ensure that essential food service equipment was maintained in a safe and functional condition in the main kitchen. During observation, the heated plate dispenser/lowerator was found completely disconnected from electrical power, with its power cord unplugged and coiled on the floor beside the unit. Staff were placing plates on top of the broken dispenser during trayline service, and the internal heating elements were inactive, leaving the unit cold to the touch. The lunch plates stacked inside the dispenser and being used for resident meal service were unheated and room temperature. Staff interviews confirmed the dispenser had been broken and out of service for over six months. A cook stated the kitchen manager had been informed when the malfunction first occurred and reported that the last time the unit was plugged in, it sparked fire, after which staff disconnected it and left it unplugged. The dietary manager acknowledged the equipment was broken and that staff were using it only to hold plates during trayline service, while also stating the plates were not heated. The NHA said the unit was damaged beyond repair, a new dispenser had been purchased, and there was no interim protocol to address the service gap.
Failure to Complete Annual CNA Performance Reviews and Related In-Service Education
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and failed to provide regular in-service education based on the outcome of those reviews for three of five CNAs reviewed. Annual performance reviews were requested for CNA #3, CNA #7, and CNA #8. The facility provided a review for CNA #3 that was completed on 4/30/25, but it was unable to provide a review for CNA #7, and the review provided for CNA #8 did not include a completion date. The evaluation for CNA #8 showed that the employee failed to meet expectations in two competency areas, communication and punctuality. There was no documentation showing that CNA #8 received education related to those deficiencies. During interviews, the NHA stated that corporate guidelines were to complete reviews once for all employees in May each year, the regional vice president said he would bring the issue to corporate for discussion regarding the regulatory requirement for reviews at least every 12 months, and the staff development coordinator stated that unit managers were responsible for completing employee reviews and that he would provide additional training if needed based on review outcomes.
Infection Control Failures in Room Cleaning and Disinfection
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection in two of three units. Surveyors observed housekeeping staff cleaning resident rooms in ways that did not follow hygienic cleaning practices, including cleaning the inside of a sink bowl and then the outside of the sink and counter with the same cloth, and using the toilet bowl brush on the top of the toilet bowl rim before wiping the toilet seat with the same cloth. Surveyors also observed a hallway doorknob sprayed with disinfectant and wiped immediately, rather than allowing the disinfectant to remain wet for the required contact time. In one single-occupancy room, a housekeeper sprayed Virex disinfectant on the sink, wiped the inside of the sink bowl, then wiped the outside of the sink and counter, and also wiped the paper towel dispenser and soap dispenser. In another room, a housekeeper sprayed Virex on a rag and wiped a bedside table; the surface was dry within minutes and did not remain wet for the full dwell time listed in the manufacturer instructions. In the double-occupancy room, a housekeeper again sprayed the sink with Virex and wiped the inside and outside of the sink with the same cloth, then cleaned the toilet bowl rim and toilet seat with the same cloth after using the toilet bowl brush on the rim. Interviews showed staff understood some aspects of cleaning but gave inconsistent information about dwell time and cleaning sequence. Housekeeping staff stated they had been trained briefly and described high-touch surfaces such as bedside tables, call lights, door knobs, and bathroom fixtures. The housekeeping supervisor stated the sink should be cleaned from the outside to the inside, toilets should be cleaned from top to bottom, and surfaces must stay wet for the full dwell time, while the infection preventionist stated that if a surface does not stay wet long enough, it is not adequately disinfected and viruses and bacteria are not being killed.
Failure to Provide Clean Clothing and Launder Soiled Laundry
Penalty
Summary
The facility failed to ensure Resident #90 was treated with respect and dignity by not ensuring he had clean clothing available and laundered. Resident #90 was greater than 65 years old, admitted with diagnoses including COPD with exacerbation, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. His MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15, and he required setup assistance with eating and moderate assistance with toileting and dressing. On observation, Resident #90 was seen wearing the same blue jeans and black t-shirt on multiple days, and the t-shirt was soiled with food stains. His closet contained only a limited amount of clean clothing, while soiled clothing was piled in a bag at the bottom of the closet. During interview, the resident stated he had been wearing the same clothes since 5/9/26, had asked staff several times to take his soiled clothes to the laundry, and believed his laundry had not been taken care of since he had been at the facility. He said he was saving his last clean outfit for discharge and was upset that he did not have clean underwear to wear. The dressing task sheet documented that the resident was independent with changing his own clothing on several occasions, but staff interviews showed there was no system to ensure residents always had clean clothes. CNAs and the housekeeping supervisor stated laundry was collected and completed daily, but also acknowledged they did not track whether a resident’s laundry requests were consistently completed. Staff said residents were expected to let them know when laundry was needed, and the DON stated CNAs should ask residents daily if clothing needed laundering and staff should notice if a resident had not changed for days.
Failure to Promptly Resolve Grievances for Missing Personal Property
Penalty
Summary
The facility failed to ensure prompt efforts to resolve resident grievances for two residents regarding missing personal property. One resident, who had severe cognitive impairment with a BIMS of 3 and diagnoses including type 2 diabetes mellitus, cognitive communication deficit, chronic fatigue, muscle weakness, restless legs syndrome, and major depressive disorder, had hearing aids, a storage case, and a charging port reported missing. The resident’s representative stated the social services director told her the items could not be located and suggested the resident may have thrown them away, but the representative said the facility did not explain whether an investigation was underway and did not resolve the matter to her satisfaction. Record review showed a grievance form was completed by the SSD after the hearing aids were reported missing, but there was no documentation that the concern was resolved. A later grievance summary stated the facility considered the matter resolved and planned to order a pocket talker, but the resident’s representative did not approve that replacement. The representative said she wanted the hearing aids replaced because she believed the facility failed to protect the resident’s property and failed to investigate the disappearance. The resident later stated she had been told the hearing aids were being repaired and would be returned when repairs were completed. A second resident, who was cognitively intact with a BIMS of 15 and diagnoses including chronic respiratory failure with hypoxia, chronic diastolic CHF, type 2 diabetes mellitus, major depressive disorder, and anxiety disorder, reported that two boxes of personal Christmas ornaments with sentimental value went missing from her room after the holidays. She said she notified the NHA immediately, but she was not given a grievance form, did not hear back, and the items were not found. The grievance log contained no entry for this concern. Staff interviews confirmed the SSD was not aware of the missing ornaments, an LPN knew about the missing items but did not complete a grievance form or document the concern, and the NHA acknowledged she did not complete a grievance form or follow up to ensure the resident’s concern was resolved.
Failure to Investigate Missing Resident Property
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of residents’ property for two residents. Facility policy stated residents have the right to be free from misappropriation of property and that the facility must establish policies and procedures to investigate such allegations. The report found that the facility did not complete investigations into missing property for either resident, despite staff and family reports that items were missing and despite the facility’s awareness of the incidents. Resident #44, who had diagnoses including type 2 diabetes mellitus, cognitive communication deficit, chronic fatigue, muscle weakness, restless legs syndrome, and major depressive disorder, had a 4/9/26 MDS showing severe cognitive impairment with a BIMS score of 3. The resident’s representative reported that the resident’s hearing aids, storage case, and charger were missing and said the SSD told her the items could not be located and that the resident had thrown them away. The representative said the facility did not explain that an investigation was underway and that she was asked to contribute toward replacement. The resident also said she was told the hearing aids were being repaired. Record review showed the care plan addressed hearing deficits and a history of throwing away hearing aids and equipment, but there was no documentation that the facility investigated how the hearing aids and accessories went missing or whether they were stolen or misplaced. Resident #66, who had diagnoses including chronic respiratory failure with hypoxia, chronic diastolic CHF, type 2 diabetes mellitus, major depressive disorder, and anxiety disorder, had a 5/7/26 MDS showing cognitive intactness with a BIMS score of 15. The resident reported that two boxes of personal Christmas ornaments with sentimental value went missing from her room after the holidays and that she notified the NHA immediately. She stated she was not given a grievance form, did not hear back, and the items were not found. The NHA acknowledged that the facility had not investigated the allegation and said she asked an activities staff member to help look for the ornaments but did not follow up. The NHA also stated she felt the ornaments were not a big deal to the resident, although the resident said they were sentimental.
Baseline Care Plan Missing Wheelchair Safety Belt Use
Penalty
Summary
The facility failed to develop an acute/baseline care plan for one resident reviewed for care planning, specifically by not including the resident’s makeshift wheelchair safety belt use on the baseline care plan. The resident was admitted with diagnoses including a nondisplaced spiral fracture of the left tibia, osteoporosis, muscle weakness, spastic hemiplegic cerebral palsy, and lack of coordination. The MDS showed the resident was cognitively intact with a BIMS score of 15, used a wheelchair, required partial assistance with self-care, had impaired movement in both lower extremities, and needed substantial to maximal assistance with upper body dressing. During observation, the resident was seen sitting in her room with a gait belt wrapped around her waist and wheelchair. The resident stated she wanted to use the gait belt so she would not slide out of the wheelchair and demonstrated that she could unclip it herself. Review of the resident’s Kardex and baseline care plan did not reveal guidance or documentation regarding the makeshift wheelchair safety belt, and the care plan did not clarify whether the resident could remove it independently. Staff interviews confirmed the belt was being used with the resident’s wheelchair, but documentation was lacking. A CNA stated the resident wore the gait belt around her waist and wheelchair for positioning and had previously seen the resident remove it herself. An LPN stated the belt could potentially be a restraint and that the resident had the ability to take it off herself, but could not find it documented in the care plan. Rehabilitation staff and OT staff stated the resident had recently started using the personal wheelchair and gait belt, that no assessment had yet been completed regarding the belt, and that the resident was able to adjust and remove it.
Failure to Provide Personalized Activity Programming
Penalty
Summary
The facility failed to provide ongoing programs that supported resident choices of activities and engaging programming based on the comprehensive assessment and care plan for one resident. Resident #89 had diagnoses of vascular dementia with agitation and depression, and the 5/5/26 MDS showed severe cognitive impairment, short- and long-term memory issues, and dependence on staff for all ADLs. The MDS also identified activities that were very important to the resident, including listening to music, watching movies, being read to, and participating in animal-related activities. The resident’s activity care plan, revised 3/19/26, documented that she was not alert and could not make her activity needs known, and it listed preferences for music, reading, TV, animal visits, and coloring. Interventions included encouraging social participation during care, one-on-one interactions, and use of a toy, busy blanket, or baby doll for comfort. However, the activity participation record from 2/29/26 to 5/14/26 showed the resident participated in TV daily but did not document participation in her preferred activities as expected. She participated in 6 of 35 music-related activities, 1 of 10 movie opportunities, and none of 17 pet visits or 16 nail care activities, with no documented refusals for those activities. Observations showed the resident often remained alone without meaningful engagement. During one continuous observation, she was asleep in bed with no music playing or other meaningful activity, later was placed in a wheelchair outside her room holding a stuffed animal, and remained in the hallway without staff engagement. During another observation, she was lying in bed with the TV on, and staff did not assist her to the scheduled radio activity. The resident’s representative stated she often found her mother alone without the stuffed animals or busy boxes provided and wanted to see her involved in social activities, noting that sitting alone was not acceptable.
Failure to Provide Hearing Assistive Devices
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices were provided to maintain hearing abilities for Resident #44, who had diagnoses including type 2 diabetes mellitus, cognitive communication deficit, chronic fatigue, muscle weakness, restless legs syndrome, and major depressive disorder. The resident’s MDS indicated cognitive impairment with a BIMS score of 3 out of 15 and that hearing aids were required. The facility policy stated residents must receive proper treatment and assistive devices to maintain vision and hearing abilities, including hearing aids and amplifiers if necessary. Resident #44’s hearing aids were reported missing and had not been replaced. The resident’s representative said the missing hearing aids created a severe communication barrier and made phone communication and meaningful interaction difficult. Observations showed the resident repeatedly leaned forward, pointed to her ears, said she could not hear, and asked what was being said. On other occasions, the resident was in her room without hearing aids and no alternative communication device was available. Staff interviews confirmed the hearing aids had been missing for weeks, communication was difficult without them, staff had to speak very loudly into the resident’s ears, and no alternative communication device was available. The SSD stated the resident required assistance to wear the hearing aids and that the staff was supposed to maintain and safeguard them, but the resident did not currently have an alternative communication device.
Oxygen concentrators were set below ordered flow rates for two residents
Penalty
Summary
The facility failed to ensure that two residents who required oxygen therapy received respiratory care consistent with physician orders and professional standards of practice. Resident #16 had diagnoses including COVID-19, COPD, pneumonia due to COVID-19, interstitial pulmonary disease, acute and chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The physician ordered oxygen at 4 LPM continuously via nasal cannula, but repeated observations showed the oxygen concentrator set at 3.5 LPM while the resident was receiving oxygen through the nasal cannula. Nursing documentation in the MAR reflected 4 LPM, but the observed setting did not match the order. Resident #90 had diagnoses including COPD with exacerbation, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The physician ordered oxygen at 3 LPM continuously via nasal cannula, yet observations on multiple occasions showed the concentrator set at 2.5 LPM while the resident was receiving oxygen. The resident stated he did not adjust his own oxygen concentrator because he did not want to be short of breath, and said the nurse adjusted it if needed. Staff interviews confirmed that CNAs checked oxygen levels during vital signs, that the nurse entered results into the EMR, and that Resident #90 should have been receiving 3 LPM per the order. Facility staff also acknowledged the mismatch between the ordered and observed oxygen settings. A CNA stated oxygen settings were checked during vitals and that staff could access the EMR for oxygen orders. An RN confirmed Resident #90’s concentrator was set at 2.5 LPM at the time of interview even though the order was for 3 LPM, and said it was important to follow physician orders for resident safety and well-being. The DON stated she expected staff to follow oxygen orders and noted that if a resident was not compliant, staff should document it in progress notes and the care plan.
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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 Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allison Care Center | 0 mi | ★★★★★ | 2 | 0 |
| Harmony Pointe Care Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Cedars Healthcare Center | 1.6 mi | ★★★★★ | 22 | 0 |
| Ahc Of Lakewood, Llc | 1.6 mi | ★★★★★ | 6 | 0 |
| Edgewater Health And Rehabilitation | 1.6 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.