Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Westhaven Community during CMS and state inspections, most recent first.
Improper glove use during meal service was observed in 2 dining rooms. A Culinary Assistant wore a glove while preparing resident lunch plates and touched multiple surfaces and scoop handles before placing buns on plates. In another dining room, a Culinary Assistant changed gloves between plates but still touched scoop handles, dietary cards, menus, food packaging, condiment packets, silverware, and a resident's arms and shoulders before handling food. The RD stated the glove use was inappropriate, and the facility policy identified gloves as single-use items that must be discarded after the task.
Unobserved Medication Administration: Staff failed to obtain an order for self-administration and left a resident’s morning meds on a dining room table without direct observation. The resident had stroke, DM, depression, and mild cognitive impairment, and staff reported they sometimes leave pills on the table while passing meds. An LPN confirmed the resident had no self-administration order and the facility policy required staff to stay with the resident until meds were swallowed.
Failure to Offer or Hold Admission Care Conferences: The facility did not document offering or holding admission care conferences for two residents. One resident had intact cognition and no record of a care conference after admission assessments were completed, while the first documented conference occurred with quarterly assessments and did not show whether the resident attended or declined. Another resident with severe cognitive impairment had no documented conference after readmission, and family reported they were not invited or present. The MDS Coordinator acknowledged the lack of documentation for both residents.
Failure to prevent deterioration of a heel pressure injury occurred for a resident with DM, depression, and HTN who was identified as at risk for pressure ulcers. The care plan and pocket care plan lacked specific prevention interventions, one Braden Scale was incomplete, and treatment records for betadine to the heel twice daily were missing many signatures. The heel injury progressed from redness with eschar to an unstageable wound and later documentation of deep tissue injury, with measurements increasing over time.
A resident with stroke, DM, depression, and mild cognitive impairment had repeated choking, coughing, and emesis episodes during meals and while taking pills. ST documented suspected esophageal dysphagia and recommended full meal supervision, but observations showed the resident eating in the dining room without nursing staff present, while staff said nursing only came in for med pass and the DON cited staffing limits and the resident’s refusal of the assisted dining room.
Incorrect puree portion sizes were served during lunch service when dietary staff prepared and portioned puree philly steak sandwich, hot dog with bun, and beets using inconsistent measurements and scoop assignments. A cook remeasured the items and labeled them with scoop sizes that did not match the Pureed Diet Portion Sizes/Scoops chart, and a culinary assistant served the puree items to residents using those scoops. The RD stated staff should measure puree foods correctly using the volume method and follow the chart for scoop size and number of scoops.
Failure to use EBP during catheter care. A resident with an indwelling urinary catheter, renal insufficiency, UTI, and DM had a care plan that did not address EBP for the catheter. Two CNAs were observed providing catheter care without wearing EBP, and both later acknowledged they should have worn them. The DON stated staff are expected to wear EBP for residents with catheters.
The facility failed to follow proper infection control practices, including not disinfecting medical equipment and not changing gloves between tasks, leading to potential cross-contamination. An LPN did not clean a spacer and mask after inhaler use, and a CNA did not change gloves after providing pericare. Additionally, insulin needles were improperly recapped, and medical equipment was not disinfected between uses.
A facility failed to accurately transcribe a physician's order for a resident's oxygen therapy, resulting in the omission of the order from the MARs for two months. The resident, on hospice care with conditions like CHF and atrial fibrillation, used oxygen for comfort, but the facility's documentation did not reflect this. Observations and interviews highlighted discrepancies in staff awareness and documentation of the resident's oxygen use.
A resident with multiple diagnoses was observed receiving oxygen at 3 liters, contrary to the physician's order of 2 liters. The MAR sheets showed unauthorized changes to the oxygen setting, and staff interviews revealed a lack of adherence to the prescribed settings. The facility lacked protocols for adjusting oxygen settings, requiring physician contact for changes.
The facility exceeded the acceptable medication error rate with two residents receiving incorrect insulin doses. An LPN failed to follow manufacturer instructions for insulin administration, leading to an 8% error rate. One resident with diabetes and renal insufficiency received an incomplete dose of Novolog insulin, while another with diabetes and macular degeneration received an improperly administered dose of Lispro insulin.
Two residents in an LTC facility received incorrect insulin doses due to improper administration by LPNs. One resident with diabetes and renal insufficiency was given Novolog insulin without following the manufacturer's instructions, resulting in a potential underdose. Another resident with diabetes and macular degeneration received Lispro insulin without proper priming or dose confirmation. The facility lacked specific policies for insulin flexpen use, leading to these significant medication errors.
The facility failed to securely store medications, with over-the-counter drugs found in an unlocked kitchen cupboard and a treatment cart left unlocked with resident-labeled supplies. Additionally, unlabeled inhalers were found in a resident's room. Staff acknowledged the need for secure storage, as per facility policy.
Improper Glove Use During Meal Service
Penalty
Summary
The facility failed to properly wear and change gloves during meal services in 2 of 2 dining rooms observed. In the Westown independent resident dining room, a Culinary Assistant wore a glove on one hand while preparing resident lunch plates and used the same gloved hand to touch the refrigerator door, cabinet door, countertop, and scoop handles before placing buns on resident plates. In the Bistro resident assist dining room, another Culinary Assistant prepared resident lunch plates and, after washing hands and putting on new gloves before each plate, touched scoop handles, dietary cards, menus, and food packaging before handling the bread for the plates. During the Bistro meal service, the Culinary Assistant also delivered plates and assisted a resident with meal set-up. While wearing gloves, the staff member touched condiment packets from a bowl, silverware, and the resident's arms and shoulders, then touched sandwiches to cut or prepare them as requested. The Registered Dietitian stated these glove-use practices were inappropriate. The facility policy stated that food service employees are to use utensils such as tongs, gloves, deli paper, and spatulas as tools to prevent foodborne illness, and that gloves are single-use items that must be discarded after completing the task for which they are used.
Unobserved Medication Administration
Penalty
Summary
The facility failed to obtain an order for self-administration of medication and allowed Resident #57 to consume medications without observation. Resident #57’s MDS dated 1/6/26 listed diagnoses of stroke, diabetes, and depression, and a BIMS score of 12 indicating mild cognitive impairment. On 4/30/26 at 8:18 AM, Resident #57 was observed sitting at a dining room table with several pills in a cup in front of her. Staff D, a CMA, stated Staff A, an LPN, had prepared the resident’s medications. During the observation, Resident #57 was seen drinking fluids and covering her mouth with her face turning red, and Staff A propelled her to her room while the pills remained on the table. Staff D left the dining room with the cup of pills still on the table and no nursing staff present in the area. Staff A later returned, removed the cup of pills, and took it to Resident #57’s room. Staff B, an LPN, stated the resident did not have an order to self-administer medications and that the policy was to observe residents take their medications. Staff A stated she had placed the resident’s morning medications on the table and that she does this for residents while passing medications, keeping an eye on them to make sure they take the pills. The resident stated staff always leave her medications on the table because she does not want to take them until after she eats.
Failure to Offer or Hold Admission Care Conferences
Penalty
Summary
The facility failed to offer or hold an admission care conference for 2 of 17 residents reviewed for care plans. Resident #1 had a BIMS score of 14, indicating intact cognition, and was admitted to the facility on [DATE]. The clinical record did not contain documentation that a care conference was offered or held after the admission comprehensive assessments were completed. The first documented care conference occurred on 2/11/26 and coincided with the quarterly comprehensive assessments completed by 2/3/26. The Care Plan Conference Summary sheet dated 2/11/26 did not document whether Resident #1 attended the conference or declined to attend, and the resident could not recall whether they participated in a care plan meeting since admission. Resident #30 had a BIMS score of 6, indicating severe cognitive impairment, and was admitted on [DATE] after a prior discharge on 11/11/25. The record showed admission assessments completed on 9/19/25 and 12/24/25, with a quarterly assessment completed on 1/26/26, but no documentation identified that a care conference had been held or offered since the readmission. The resident’s family stated they had not attended or been invited to a care conference since the December readmission. The MDS Coordinator acknowledged there was no documentation of a care conference for Resident #30 since readmission and stated that, without documentation, the conference was most likely not held; the coordinator also stated the same for Resident #1.
Failure to Prevent Deterioration of a Heel Pressure Injury
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with depression, diabetes mellitus, and hypertension who had a BIMS score of 13 and was identified as at risk for pressure ulcers. The resident’s care plan included diabetic foot care, weekly diabetic skin checks, ordered treatments, a pressure reducing mattress and chair cushion, nutrition and hydration encouragement, and skin checks with cares, but it lacked specific preventative interventions to prevent pressure areas. The pocket care plan also lacked preventative interventions, and one Braden Scale dated 2/11/26 was incomplete, while an earlier Braden Scale score of 18 indicated pressure ulcer risk. The resident reported right heel pain, and staff observed a 4.2 cm by 4.4 cm red area that was blanchable with a 1.7 cm by 1.3 cm area of black eschar and dried skin in the center. The resident stated someone ran over his heel with the wheelchair leg. An ARNP assessed the area and ordered betadine twice daily and open to air, with a PA-C follow-up; the PA-C later documented the area could be from trauma from bumping or rubbing with a wheelchair wheel or could be pressure, and identified it as unstageable at that time. The PA-C later documented the injury as an unstageable heel injury and continued the same orders, while compression socks were held until the wound healed. Subsequent wound measurements showed the right heel injury changed over time, including documentation of 100% eschar, unstageable eschar, and later deep tissue injury, with measurements increasing to 5.0 cm by 4.9 cm and later remaining documented as eschar. The March and April treatment sheets for betadine to the right heel twice daily and open to air lacked many signatures, indicating the treatment was not completed. The facility policy stated residents admitted without pressure injuries would remain free of pressure injuries unless clinically unavoidable and that care plans and interventions should be individualized and communicated to CNAs, while the DON stated the facility used the Braden Scale and expected staff to sign off when treatments were completed.
Failure to Provide Meal Supervision for Resident with Swallowing Difficulty
Penalty
Summary
The facility failed to provide adequate supervision in the dining room during meals for a resident with recommendations for full supervision. Resident #57 had diagnoses including stroke, diabetes, and depression, and a BIMS score of 12 indicating mild cognitive impairment. The resident’s record showed repeated choking and swallowing-related events, including coughing, redness in the face, emesis, and choking episodes during meals and while taking pills. The Speech Therapy evaluation documented suspected esophageal dysphagia based on reported emesis after intake, heartburn, and food sticking, and recommended full supervision during meals. Despite those recommendations, observations showed Resident #57 eating in the Westown dining room with no nursing staff present, including during lunch and breakfast. Staff interviews confirmed that nursing staff were not present in the Westown dining room throughout meals and only came in when passing medications, while the dietary aide monitored residents and sought nursing help if a resident started coughing. The DON stated the resident did not want to go to the assisted dining room and that there was not enough staff to provide 1:1 supervision in the independent dining room, even though the Administrator stated the expectation was to follow therapy recommendations. The resident stated she had ongoing choking and coughing problems and had not been spoken to about going to the assisted dining room, though she was willing to try it.
Incorrect puree portion sizes during lunch service
Penalty
Summary
The facility failed to ensure appropriate serving sizes for puree lunch items for 5 of 6 residents receiving a puree diet. On 4/29/26, the puree hot lunch consisted of a philly steak sandwich with peppers and onions and a hot dog on a bun as the alternative, with beets offered instead of baked beans because beans were not available. Staff E, Cook, prepared the puree items in the morning and measured out four servings of puree philly steak sandwich, three servings of puree hot dog with bun, and six servings of puree beets, placing them in separate measuring cups. After preparing the items, Staff E used the Pureed Diet Portion Sizes/Scoops chart to determine serving sizes, but the items were remeasured and labeled inconsistently. The philly steak sandwich was remeasured at 4.5 cups and assigned a grey and black scoop; the hot dog with bun was remeasured at 2.5 cups and assigned a grey and green scoop; and the beets were remeasured at 3 cups and assigned a grey scoop. At lunch service, Staff H, Culinary Assistant, served the puree items using the scoop sizes placed on the pans, and for items with two scoops, both scoops were used for each plate. The Registered Dietitian stated dietary staff should correctly measure puree food items using the volume method and expected staff to use the scoop size and number of scoops listed on the Puree Diet Portion Sizes/Scoops chart. The facility did not have a specific policy outlining the procedure used to determine appropriate puree food portion sizes.
Failure to Use Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to provide appropriate infection prevention practices by not following enhanced barrier precautions (EBP) for one resident with an indwelling catheter. Resident #8’s MDS documented a BIMS score of 14, indicating intact cognition, and listed renal insufficiency, urinary tract infection, diabetes mellitus, and an indwelling catheter. The resident’s care plan dated 4/9/26 did not mention EBP related to the indwelling catheter. During an observation on 4/29/26 at 12:05 pm, Staff F and Staff G, both CNAs, were observed providing catheter care without wearing EBP. In an interview later that day, both staff members acknowledged they should have worn EBP while providing catheter care. The facility policy stated that EBP are recommended for residents with an indwelling medical device, including an indwelling urinary catheter, and identified device care or use of a urinary catheter as a high-contact activity requiring gown and gloves. The DON stated the expectation for staff is to wear EBP for residents with catheters.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control techniques, leading to potential cross-contamination and infection risks for several residents. During medication administration, a Licensed Practical Nurse (LPN) did not disinfect a spacer and mask used for a resident with chronic obstructive pulmonary disease and heart failure after administering an inhaler. The facility's policy lacked specific instructions for cleaning inhaler administration devices, and the Co-Director of Nursing (DON) expected staff to rinse the mask with water and air dry it, which was not done. In another instance, a Certified Nursing Assistant (CNA) failed to change gloves and sanitize hands after providing pericare and transferring a resident to a commode. The CNA continued to wear the same gloves while handling various items, including a mechanical lift, which was not disinfected after use. The facility's hand washing policy required hand hygiene and glove changes between tasks, which were not followed, leading to potential contamination. Additionally, the facility did not have a policy for insulin flexpen use, resulting in an LPN recapping needles, contrary to the manufacturer's instructions and facility policy. Medical equipment such as carts and blood pressure cuffs were not disinfected between resident use, and staff did not change gloves or sanitize hands between different medication administrations, such as ear and eye drops. These actions violated the facility's standard precautions policy, which required hand hygiene and equipment disinfection to prevent cross-contamination.
Failure to Transcribe Oxygen Order Accurately
Penalty
Summary
The facility failed to provide services that met professional standards by not accurately transcribing a physician's order for a resident's oxygen therapy. The resident, who was admitted with diagnoses including congestive heart failure, atrial fibrillation, and coronary artery disease, was on hospice care and required supplemental oxygen for comfort. Despite having an order for oxygen therapy, the facility did not include this order in the Medication Administration Records (MAR) for March and April 2025, nor was it present in the signed Physician's Order Summary. This oversight resulted in the resident's oxygen usage not being documented as required. Observations and interviews revealed discrepancies in the facility's awareness and documentation of the resident's oxygen use. A portable oxygen concentrator was observed in the resident's room, and the resident confirmed using oxygen as needed. However, the Co-Directors of Nursing were unaware of the resident's oxygen use and the presence of an oxygen concentrator in the room. The facility's failure to transcribe the oxygen order accurately onto the MARs and the Physician's Order Summary led to a deficiency in meeting professional standards of care.
Failure to Adhere to Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide oxygen therapy as prescribed by the physician for a resident with intact cognition and multiple diagnoses, including atrial fibrillation, chronic obstructive pulmonary disease, coronary artery disease, and heart failure. The resident was observed receiving oxygen at a setting of 3 liters, contrary to the physician's order of 2 liters to maintain oxygen saturation at or above 89%. The Medication Administration Review (MAR) sheets indicated discrepancies in the recorded oxygen settings, with an unauthorized change to 3 liters documented in February 2025, and no subsequent adjustments or updates to reflect the physician's order. Interviews with staff revealed a lack of awareness and adherence to the prescribed oxygen settings. A Licensed Practical Nurse (LPN) was unable to recall the current oxygen order and noted that the resident typically received 3 liters, based on their assessment of the resident's comfort. The facility lacked a protocol or standing orders for titrating oxygen settings, requiring nursing staff to contact the physician for any changes. The facility's policy on oxygen therapy administration, revised in October 2022, mandates that the oxygen flow rate be set to the prescribed dosage, which was not followed in this case.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during observations of medication administration. Two residents were involved in the errors. The first resident, diagnosed with diabetes and renal insufficiency, was supposed to receive 8 units of Novolog insulin. However, the LPN administering the insulin did not follow the manufacturer's instructions, which required the needle to remain in the skin for at least 6 seconds to ensure the full dose was delivered. Instead, the needle was removed after only one second, potentially compromising the effectiveness of the insulin dose. The second resident, diagnosed with diabetes and macular degeneration, was to receive 6 units of Lispro insulin. The LPN did not properly prime the insulin pen or ensure the needle was in place for the required time as per the manufacturer's instructions. The pen was held in place for only 3-4 seconds instead of the recommended 5 seconds, and the LPN did not verify that the dose counter showed zero after administration. These actions led to a failure in ensuring the resident received the correct insulin dosage, contributing to the facility's medication error rate exceeding the acceptable threshold.
Insulin Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer insulin correctly to two residents, leading to significant medication errors. Resident #31, who has diabetes and renal insufficiency, was observed receiving Novolog insulin via a flexpen. The LPN administering the insulin did not follow the manufacturer's instructions, which require the needle to remain in the skin for at least 6 seconds to ensure the full dose is delivered. Instead, the needle was removed after only one second. The facility lacked a specific policy for insulin flexpen use, and the Co-Director of Nursing was unaware of the proper procedure, relying instead on manufacturer instructions. Similarly, Resident #41, who has diabetes and macular degeneration, was administered Lispro insulin incorrectly. The LPN did not prime the insulin pen properly, as required by the manufacturer's instructions, and did not hold the needle in the skin for the recommended 5 seconds. The LPN also failed to check that the dose counter showed zero after administration, which is necessary to confirm the full dose was given. These actions resulted in the residents potentially receiving incorrect insulin dosages, as the facility did not have adequate procedures in place to ensure proper insulin administration.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications, as observed during a survey. Over-the-counter medications such as Pepto-Bismol, Ibuprofen, Tylenol, Tylenol Arthritis, Tums, and allergy relief were found in an unlocked cupboard in a kitchen prep area, which did not have a secured entrance. The Certified Dietary Manager acknowledged these medications were for staff use. Additionally, the 100-hall treatment cart was found unlocked, containing Biofreeze, Nystop powder, Diclofenac cream, and dressing supplies labeled with resident names. Furthermore, in a resident's room, Albuterol and Budesemide inhalers were observed on a bedside table without any labeling. Staff interviews revealed that medications are typically stored on the medication cart or in the medication room, and resident inhalers should be on the medication cart. The Co-Directors of Nursing acknowledged that the over-the-counter medications in the kitchen should have been locked. The facility's undated policy on Medication Labeling and Storage requires medications to be properly labeled and stored in locked carts or cabinets, with unlabeled containers to be destroyed according to state and federal laws.
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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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| Eastern Star Masonic Home | 0.4 mi | ★★★★★ | 11 | 0 |
| Accura Healthcare Of Ogden, Llc | 6.7 mi | ★★★★★ | 3 | 0 |
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| Green Hills Health Care Center | 13.4 mi | ★★★★★ | 1 | 0 |
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