Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellbrooke Of Westfield during CMS and state inspections, most recent first.
Missing PASARR Screening: A resident with Parkinsonism, major depressive disorder, and dementia had physician orders for escitalopram and quetiapine, but no PASARR screening was found in the clinical record. An RN stated the PASARR was missed.
Medications were administered outside physician-ordered hold parameters for two residents. One resident with diabetes, dementia, and CHF received Novolog insulin at breakfast, lunch, and dinner even when blood sugars were below the ordered hold threshold, and another resident with HTN and a prior MI received isosorbide mononitrate when systolic BP was above the ordered limit. The DON and Clinical Support Nurse acknowledged the orders were not followed.
A QMA took and shared an unauthorized photo of two residents, one of whom was nude and both with severe cognitive impairment, by sending it via text to a CNA. Staff interviews confirmed that only designated employees were permitted to take resident photos, and the QMA was not authorized to do so.
The facility did not accurately complete PASARR documentation for two residents, omitting mental health diagnoses and prescribed psychotropic medications such as aripiprazole, clonazepam, and zolpidem. Staff interviews confirmed the PASARRs were incomplete and that there was no facility policy related to PASARR.
The facility did not ensure that care plans were prepared and reviewed by an IDT with resident and representative participation, as required. For a resident with dementia, there was no documentation supporting behavioral claims or evidence of an IDT meeting before the care plan was initiated. Additionally, two other residents did not have documented quarterly care plan meetings, contrary to facility policy.
Two residents did not receive safe and appropriate respiratory care when one was found with a nasal cannula but the oxygen concentrator was turned off despite a physician's order, and another used oxygen without a documented physician's order. Staff and the ADON confirmed the lack of proper orders and adherence to facility policy, resulting in a failure to follow prescribed respiratory care protocols.
A medication cart contained an unlabeled insulin pen, and narcotic count sheets for two medication carts had missing signatures from both oncoming and off-going nursing staff during shift changes. Facility policies require medications to be labeled with the resident's name and narcotic counts to be signed by both staff members at each shift change, but these procedures were not consistently followed.
A resident with multiple health conditions reported not always receiving lunch meals, and review of her medical record revealed missing documentation of lunch meal intakes on several occasions. Staff interviews confirmed that meal intakes should be recorded in the EHR before shift end, but these entries were absent, in violation of facility policy.
Missing PASARR Screening
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for Resident 13. The resident’s clinical record showed diagnoses including Parkinsonism, major depressive disorder, and dementia. Physician orders dated 10/3/25 directed escitalopram 5 mg for depression and quetiapine 50 mg for depression. Survey review found no PASARR screening in the resident’s clinical record. During interview, Clinical Support Nurse 1 stated the facility did not have a PASARR for Resident 13 and that it was missed.
Medications Given Outside Ordered Hold Parameters
Penalty
Summary
The facility failed to ensure medications were held according to physician orders for 2 residents reviewed for quality of care. Resident 3 had diagnoses including type 2 diabetes mellitus, dementia, and chronic diastolic congestive heart failure. The resident’s care plan directed staff to administer hypoglycemic medication as ordered. A physician’s order for Novolog FlexPen U-100 insulin at breakfast and lunch required the medication to be held for blood sugar less than 150, but the MAR showed multiple instances in January and February 2026 when the insulin was administered despite blood sugars below that threshold. Resident 3 also had a physician’s order for Novolog FlexPen U-100 insulin at dinner with the same hold parameter of blood sugar less than 150. The MAR showed multiple dinner administrations in January and February 2026 when the resident’s blood sugar was below 150, including readings such as 124, 99, 133, 98, 129, 108, 96, 109, 136, 98, 117, 100, 127, 122, 93, 99, and 107. During interviews, Clinical Support Nurse 2 and the DON acknowledged that medication had been administered against the physician’s order and that hold parameters were to be followed. Resident 58 had diagnoses including hypertensive emergency, primary hypertension, and myocardial infarction. The care plan indicated a potential for cardiovascular distress related to hypertension and directed staff to administer medications as ordered. A physician’s order for isosorbide mononitrate required the medication to be held for systolic blood pressure greater than 120, but the MAR showed the medication was administered when the resident’s blood pressure was 140/78. Clinical Support Nurse 2 and the DON stated that the medication had been given outside of the ordered hold parameters.
Unauthorized Photo of Residents Violates Privacy and Confidentiality
Penalty
Summary
Staff failed to maintain the privacy and confidentiality of residents' personal and medical records when a Qualified Medication Assistant (QMA) took an unauthorized photo of two residents in a hallway. One resident was nude, and the side of the other resident's face was visible in the photo. The QMA then sent this photo to a Certified Nursing Assistant (CNA) via text message. The incident was discovered when the CNA reported receiving the photo to facility management. Attempts to contact the QMA involved were unsuccessful. Both residents involved had severe cognitive impairment, as documented in their clinical records. One resident had diagnoses including anxiety disorder and stage 3 chronic kidney disease, while the other had general anxiety disorder, insomnia, and depression. Multiple staff interviews confirmed that taking photos of residents was not permitted, and only designated employees were authorized to take photos for business purposes. The QMA involved was not authorized to take or share photos of residents.
Failure to Accurately Complete PASARR for Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) was completed accurately for two residents. For one resident with diagnoses including visual hallucinations, psychosis, and major depressive disorder, the PASARR did not list all mental health diagnoses or medications, such as aripiprazole and clonazepam, which were prescribed by a physician. The PASARR also lacked a mental health diagnosis to justify the use of these psychotropic medications. Interviews with the Director of Nursing and Social Service Director confirmed that the PASARR was incomplete and needed updating. For another resident with diagnoses including insomnia and pain, the PASARR indicated no mental health diagnoses or medications, despite a physician's order for zolpidem, a sedative-hypnotic medication. The Social Service Director acknowledged that the PASARR did not include any mental health diagnoses or medications for this resident. Additionally, it was noted that the facility did not have a policy related to PASARR, although they reported following CMS guidelines.
Failure to Document Interdisciplinary Care Plan Meetings and Resident Participation
Penalty
Summary
The facility failed to ensure that care plans were prepared, reviewed, and revised by an interdisciplinary team (IDT) with the participation of residents and their representatives, as required. For one resident with Alzheimer's disease and dementia, the clinical record did not contain documentation supporting the behavioral care plan's claims of inappropriate behaviors, nor was there evidence of an IDT meeting prior to the initiation of the care plan. Interviews with staff confirmed the absence of documentation for both the alleged behaviors and the required IDT meeting. Additionally, two other residents did not have documented care plan meetings within the required quarterly timeframe. One resident was unsure when their last care plan meeting occurred, and the record confirmed the last meeting was several months prior, with no documentation of a more recent meeting. Another resident's family member reported not having attended a care plan meeting recently, and the record also lacked documentation of a recent meeting. Facility policy requires quarterly care plan meetings for all residents, but this was not consistently documented or followed.
Failure to Ensure Safe and Ordered Oxygen Therapy for Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not ensuring oxygen therapy was administered according to physician orders and by not obtaining a physician's order for oxygen use. In one instance, a resident with a history of Covid-19, chronic respiratory failure with hypoxia, and asthma was observed wearing a nasal cannula, but the oxygen concentrator was turned off despite a physician's order for oxygen at 3 liters per minute. Staff confirmed the oxygen should have been turned on, and the resident's care plan required oxygen administration per physician's orders. In another case, a resident with diagnoses including malignant neoplasm of the right main bronchus, COPD, and pan lobular emphysema was observed with an oxygen concentrator in the room and evidence of recent oxygen use, but there was no physician's order for oxygen found in either the electronic health record or the hospice binder. Staff and the ADON confirmed the absence of a written order for oxygen use, despite the resident's care plan indicating oxygen should be administered per physician's orders. Facility policies required verification of physician orders and proper documentation for oxygen administration, which was not followed in these cases.
Medication Labeling and Narcotic Count Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and documentation practices for medications and controlled substances. During an observation, an insulin pen (Lantus) was found in a medication cart without a resident's name on the label, which was confirmed by an LPN who acknowledged that the pen should have been labeled. Additionally, review of the narcotic count sheets for two medication carts revealed multiple instances where required signatures from both oncoming and off-going nursing staff were missing during shift changes. These omissions were noted on several dates for both the boardwalk south and 200 south medication carts. Interviews with nursing staff confirmed that the narcotic count sheets are expected to be signed at every shift change, as outlined in the facility's own policies. The policies require each prescription medication to be labeled with the resident's name and mandate that both oncoming and off-going staff sign the narcotic count sheets to verify reconciliation of controlled substances. The deficiencies were identified through direct observation, record review, and staff interviews.
Incomplete Documentation of Meal Intakes in Resident Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurately documented regarding meal intakes. A resident reported not receiving her lunch meal on some occasions. Upon review of her clinical record, which included diagnoses such as vitamin deficiency, repeated falls, and muscle weakness, it was found that lunch meal intake was not documented on several specific dates. Interviews with an LPN and a Clinical Support nurse confirmed that meal intakes should be recorded in the electronic health record before the end of each shift, and that refusals should be documented as such. However, the lunch meal intakes were missing from the resident's record on the identified dates, contrary to facility policy requiring such documentation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 869 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Park Village | 1 mi | ★★★★★ | 8 | 0 |
| Bridgewater Healthcare Center | 4.3 mi | ★★★★★ | 8 | 0 |
| Copper Trace Health & Living Community | 5 mi | ★★★★★ | 9 | 0 |
| Majestic Care Of Carmel | 5.6 mi | ★★★★★ | 0 | 0 |
| Harbour Manor Health & Living Community | 6 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wellbrooke Of Westfield.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.