Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westlake Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was given medications intended for another resident by an agency LPN, resulting in symptoms such as dizziness and stomachache. The error was identified after administration, and the resident was monitored for adverse effects. The DON and physician were notified following the incident.
A resident with a history of atrial fibrillation, mechanical heart valve, and recurrent DVT did not receive warfarin for seven days due to a nurse's failure to transcribe a physician's order into the EMR and MAR. This led to a subtherapeutic INR, development of a blood clot, and subsequent above-the-knee amputation. The error was discovered when another nurse identified the missing order and low INR, confirming a significant medication error.
The facility failed to maintain a sanitary and safe environment, with observations revealing unclean swamp cooler vents, shower rooms, and mechanical rooms with black discoloration. The facility's policy emphasized a safe and homelike environment, which was not upheld. Interviews confirmed the lack of work orders for these issues, and the new nursing home administrator was aware of some problems. A service contractor was scheduled to assess repairs.
The facility failed to maintain an infection control program, leading to unsanitary cleaning practices and improper storage of a resident's nebulizer. Observations showed that disinfectant surfaces were not kept wet for the required time, high-touch areas were not cleaned, and the nebulizer was stored on the floor, posing contamination risks. Staff interviews confirmed these practices were not in line with facility policies and CDC guidelines.
The facility failed to follow PASRR Level II recommendations for a resident with severe cognitive impairments and a history of mental health issues. The comprehensive care plan did not document the PASRR Level II screening and specialized services recommendations, and there was no evidence that the facility had reached out to a mental health provider for neuropsychological testing as recommended.
A resident with severe cognitive impairment and protein malnutrition did not receive necessary eating assistance, leading to inadequate food intake. Staff only provided set-up assistance and did not offer alternatives or additional food items when the resident did not eat her meal. The care plan was not updated to reflect the resident's increased need for feeding assistance, and documentation of meal assistance was inconsistent.
The facility failed to follow physician orders for a resident's cervical neck brace, leading to prolonged use and discomfort. Additionally, the facility did not properly support and position another resident in her wheelchair, resulting in improper alignment and potential complications. Staff interviews revealed a lack of communication and follow-up regarding the residents' care needs.
The facility failed to ensure adequate supervision and implement person-centered fall interventions for two residents, leading to multiple unwitnessed falls. Despite the facility's fall management policy, staff did not conduct root cause analyses or update care plans with new interventions after each fall. Additionally, required safety measures such as ensuring call lights were within reach and using non-skid socks were not consistently followed.
The facility failed to ensure residents were free from significant medication errors, affecting two residents. One resident received multiple wrong medications due to improper identity verification, and there was inadequate documentation and follow-up. Another resident's scheduled opioid medication was consistently administered too early or too late, with no incident reports or physician notifications. The facility's response was insufficient, lacking timely investigation and staff education.
Resident Administered Another Resident's Medications Due to Medication Error
Penalty
Summary
A significant medication error occurred when a resident with multiple chronic conditions, including type 2 diabetes, atrial fibrillation, heart failure, chronic kidney disease, hypertension, gout, dysthymic disorder, and insomnia, was administered medications intended for another resident. The error was made by an agency LPN, who gave the resident Lisinopril 40 mg, Duloxetine 60 mg, and Bupropion 300 mg ER, none of which were prescribed for this resident according to the computerized physician orders. The resident recalled being informed by the facility about the error and reported experiencing dizziness, stomachache, and inability to eat for 24 hours following the incident. The facility's documentation confirmed that the LPN notified the physician, DON, and the resident's representative after the error was discovered. The resident's vital signs were checked and found to be within normal limits, and the progress note indicated no discomfort or adverse reaction at the time of assessment. The DON, who had just started working at the facility the day before the incident, confirmed the details of the medication error and identified the agency LPN as the individual responsible for administering the wrong medications.
Failure to Transcribe Warfarin Order Results in Missed Doses and Serious Harm
Penalty
Summary
A significant medication error occurred when a resident with a mechanical heart valve and a high risk for deep vein thrombosis (DVT) did not receive prescribed anticoagulant therapy for seven days. The resident had a physician's order for warfarin, with dosing adjustments based on PT/INR lab results, and required close monitoring to maintain a therapeutic INR range of 2.5 to 3.5. On a specific date, a nurse received a verbal order to restart warfarin at a new dose and to recheck the INR on a later date. However, the nurse failed to transcribe this order into the electronic medical record (EMR) and the medication administration record (MAR), resulting in the resident not receiving warfarin for an extended period. This omission was not identified until another nurse noticed the absence of a current warfarin order and a critically low INR level. The resident's INR dropped to 0.97, indicating subtherapeutic anticoagulation. During this period without anticoagulant therapy, the resident developed a blood clot in the right leg, which ultimately led to an above-the-knee amputation. The facility's records and staff interviews confirmed that the missed transcription of the physician's order directly resulted in the failure to administer the medication as prescribed. The resident's medical history included atrial fibrillation, a mechanical heart valve, recurrent DVT, and significant immobility, all of which increased the risk for thromboembolic events. Documentation showed that the resident required assistance with most activities of daily living and had a care plan in place for anticoagulant therapy. The error was traced to a breakdown in the process of entering and verifying physician orders, as well as a lack of timely recognition by staff that the medication had not been administered.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed that two ceiling swamp cooler vents, two shower rooms, and eight mechanical rooms were not thoroughly cleaned and contained black discoloration on various surfaces. The facility's policy, revised in September 2024, emphasized the importance of providing a safe and homelike environment, which was not adhered to in this instance. During an environmental tour, it was observed that the hallway ceiling air vents near certain resident rooms had missing vent louvers and dark debris. The ceiling adjacent to one vent showed sheetrock damage and sagging. In the shower rooms on halls 200 and 300, there were issues such as water dripping from showerheads, non-functional exhaust fans, and black discoloration on walls and floors. The mechanical rooms across various halls exhibited sheetrock damage, black discoloration, rusty vents, and unkempt conditions, with some rooms having leaking water lines and dead gnats. Interviews with the maintenance supervisor, unit managers, and accounts manager confirmed these observations. They acknowledged the lack of work orders for the issues noted and mentioned that staff could report maintenance needs through various channels. The nursing home administrator, who was new to the facility's management, was aware of black discoloration in one mechanical room but was unsure of its location. A service contractor was scheduled to evaluate the repairs needed in one of the mechanical rooms, and temporary resident relocations were planned to facilitate these repairs.
Infection Control Deficiencies in Cleaning Practices and Equipment Storage
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. Specifically, the facility did not ensure that resident rooms were cleaned in a sanitary manner, manufacturer-recommended surface contact times were followed for effective disinfection, and nebulizers were stored and cleaned according to professional standards of practice. Observations revealed that a housekeeper did not allow disinfectant surfaces to remain wet for the required three minutes, did not sanitize the toilet brush after use, and failed to clean high-touch surfaces such as call lights, bed controls, and door handles. Interviews with the housekeeper and housekeeping supervisor confirmed these practices were not in line with the facility's infection control policies and CDC guidelines. Additionally, the facility did not ensure proper infection control practices for resident-care items and equipment. A resident's nebulizer unit, including the mouthpiece and T-piece, was observed to be stored in an unsanitary manner, touching the bed surface and the floor, and was dusty and discolored. Interviews with the LPN, DON, and IP confirmed that the nebulizer should not be stored on the floor and that this practice posed an infection control problem. The facility's policy on cleaning and disinfection of resident-care items and equipment was not followed, leading to potential contamination risks for the resident using the nebulizer. The DON and IP acknowledged the issue and indicated that immediate nursing education on proper storage of nebulizer equipment would be initiated.
Failure to Follow PASRR Level II Recommendations
Penalty
Summary
The facility failed to ensure that a Level II Preadmission Screening and Resident Review (PASRR) was completed for one resident, leading to a deficiency in maintaining the resident's highest practical medical, emotional, and psychosocial well-being. Specifically, the facility did not follow the PASRR Level II recommendations for a resident with severe cognitive impairments and a history of mental health issues. The resident's comprehensive care plan did not document the PASRR Level II screening and specialized services recommendations for mental illness, and there was no evidence that the facility had reached out to a mental health provider to establish services for neuropsychological testing as recommended. Interviews with facility staff revealed that the PASRR recommendations were not followed up on, and neuropsychological testing was not completed due to issues with the behavioral health provider. The Social Services Director acknowledged the oversight and indicated that the facility's behavioral health provider did not conduct neuropsychological testing. The Director of Nursing and the Nursing Home Administrator both confirmed that the facility should follow up on all PASRR recommendations to ensure residents maintain their quality of life.
Failure to Provide Eating Assistance for High-Risk Resident
Penalty
Summary
The facility failed to provide necessary eating assistance for a resident who required supervision and cueing and was at high risk for weight loss. The resident, who had severe cognitive impairment and severe protein malnutrition, was observed on multiple occasions sitting alone in the dining room without receiving the required assistance or cueing from staff. Despite being served meals, the resident only consumed ice cream and did not eat the main components of her meals, such as pureed meat, vegetables, mashed potatoes, or a banana. Staff did not offer any alternatives or additional food items when the resident did not eat the food on her plate. The facility's Weight Management policy indicated that residents at risk for weight change should have interventions implemented to minimize the risk, including assisted dining. However, the care plan for the resident was not updated to reflect her increased need for feeding assistance. Documentation of meal assistance was inconsistent, with numerous instances where no assistance was recorded. The registered dietitian noted that the resident needed more supervision and encouragement during meals, and the director of nursing confirmed that the resident should have received staff cueing and supervision. Interviews with staff revealed that they only provided set-up assistance for the resident's meal tray and did not offer further assistance or cueing. The certified nurse aide acknowledged that the resident would only eat a small portion of her meal and that any feeding assistance required should be documented. The director of nursing emphasized that residents at risk for weight loss should receive appropriate assistance during meals, which was not provided in this case.
Failure to Follow Physician Orders and Properly Position Residents
Penalty
Summary
The facility failed to follow hospital physician orders for Resident #35, who was required to wear a cervical neck brace for six weeks. The resident continued to wear the brace for 12 weeks due to the facility's failure to enter the physician's orders into the facility's system. Additionally, the facility did not monitor the skin under the cervical neck brace for 33 days and failed to transport the resident to her scheduled neuro-orthopedic appointment, which was crucial for evaluating the need for continued use of the brace. The resident experienced discomfort and moderate pain due to the prolonged use of the brace, which was stained and not properly maintained. The facility also failed to properly support and position Resident #51 in her wheelchair. The resident, who had anoxic brain damage and contractures, was observed leaning to the left side in her wheelchair during meal times. Staff did not attempt to reposition the resident before assisting with meals, and the resident's wheelchair had not been evaluated for proper positioning for over a year. This lack of assessment and intervention led to the resident being improperly positioned, which could contribute to further complications. Interviews with staff revealed a lack of communication and follow-up regarding the residents' care needs. The Director of Nursing acknowledged that the hospital discharge orders for Resident #35 were not correctly entered into the resident's medical records, and the facility did not follow up on missed medical appointments. Similarly, the Director of Rehabilitation and nursing staff were aware of Resident #51's positioning issues but did not take steps to address them, indicating a systemic issue in ensuring proper care and treatment for residents with specific medical needs.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and implement person-centered fall interventions for two residents, leading to multiple unwitnessed falls. Resident #33, who had severe cognitive impairment and a history of falls, experienced three unwitnessed falls within a month. Despite the facility's fall management policy, the staff did not conduct a root cause analysis or update the resident's care plan with new interventions after each fall. Additionally, the resident's call light was found out of reach, and she was not wearing non-skid socks as required by her care plan. The facility also failed to ensure that a registered nurse assessed the resident after each fall, as only licensed practical nurses documented the incidents without conducting thorough assessments or implementing new interventions. Resident #35, who had moderate cognitive impairment and a history of neck fractures, also experienced a fall that was not adequately addressed by the facility. The resident's care plan required the bed to be in the lowest position and the call light within reach, but these interventions were not followed. The resident fell out of bed, which was found in the highest position, and the call light was not within reach. The facility's investigation did not include staff interviews or new interventions to prevent future falls. The resident was sent to the hospital for evaluation and returned with no new fractures, but the care plan was not updated with person-centered interventions to prevent further falls. Interviews with staff, including the DON, revealed that the facility did not follow its own fall management policy. The DON acknowledged that immediate new interventions should have been implemented after each fall and that the care plans should have been updated with person-centered interventions. The facility's failure to conduct thorough root cause analyses and update care plans with effective fall prevention measures contributed to the repeated falls experienced by both residents.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting two residents out of the five reviewed. Specifically, Resident #51 received multiple wrong medications intended for another resident, Resident #20. The error occurred because the registered nurse (RN) did not properly verify the resident's identity before administering the medications. Following the error, there was inadequate documentation, monitoring, and follow-up for possible adverse outcomes. The resident experienced a headache and frequent urination but there was no comprehensive documentation of the medication error, provider notification, or vital sign monitoring as required by the facility's policy. Additionally, the grievance investigation conducted was insufficient and delayed, failing to identify key issues and provide timely education to the involved nurse, RN #1. The facility also did not conduct a root cause analysis or involve the interdisciplinary team in reviewing the error. The Director of Nursing (DON) acknowledged the need for further follow-up and education for agency staff on medication administration policies and procedures. Resident #70 did not receive scheduled opioid medication according to physician orders. The medication administration records revealed that the resident's oxycodone was consistently administered either too early or too late, deviating from the prescribed schedule. The facility failed to provide incident reports or progress notes indicating that the physician was notified of these medication administration errors. Interviews with the Licensed Practical Nurse (LPN) and DON revealed a lack of adherence to proper medication administration protocols and insufficient training on handling medication alerts and incident reporting. The DON admitted to being unaware of the issue and emphasized the need for training and education to prevent such errors in the future. The deficiencies highlight significant lapses in medication administration practices, documentation, and follow-up procedures within the facility. Both residents experienced potential risks due to these errors, and the facility's response to the incidents was inadequate, lacking timely investigation, proper documentation, and necessary staff education. The DON and nursing home administrator acknowledged the need for improved training and adherence to medication administration protocols to prevent future errors and ensure resident safety.
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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 Greeley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broadview Health And Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| Fairacres Manor, Inc. | 1.1 mi | ★★★★★ | 0 | 0 |
| Center At Centerplace, Llc, The | 1.6 mi | ★★★★★ | 11 | 1 |
| Life Care Center Of Greeley | 1.9 mi | ★★★★★ | 0 | 0 |
| Grace Pointe Cont Care Sr Campus, Skilled Nursing | 3.2 mi | ★★★★★ | 4 | 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 August 2026) and official state health department websites.