Below 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 Westridge Health Care Center during CMS and state inspections, most recent first.
Failure to Notify Provider and Assess Worsening Pain After Fall: A resident with dementia, chronic pain, and high fall risk was found on the floor and initially had no reported injury, but later developed repeated severe knee, leg, and generalized pain after the fall. Staff documented PRN pain meds and later bruising and swelling, yet the record lacked documentation that the MD/NP was notified when pain worsened. The resident was eventually sent to the hospital for uncontrolled pain and was found to have a right femur fracture requiring surgical fixation.
Missing Documentation for Resident and Representative Participation in Care Plan Meetings: The facility failed to document resident and family/POA participation in care plan meetings for multiple residents. Records showed several care conference notes without evidence that the resident or representative was invited, attended, or declined, while interviews with residents, a POA, and the SSD showed uncertainty about invitations and attendance. Some residents stated they did not remember regular care plan meetings, and the SSD acknowledged inconsistent documentation and missing meeting records.
The facility failed to obtain psychotropic medication consent for a new antidepressant order for one resident and for a sertraline dose increase for another resident. One resident had depression, schizoaffective disorder, and moderate cognitive impairment, and the record lacked consent for duloxetine initiation. Another resident had major depressive disorder and GAD, and the record lacked consent for a sertraline increase ordered after IDT discussion of worsening depression and anxiety.
A resident with dementia, HTN, and anorexia had significant weight loss, but the facility did not implement RD-recommended interventions or document physician notification. The resident was observed coughing while drinking thin liquids, and the record lacked evidence of ordered protein supplementation, breakfast supplement administration, or communication of the RD’s recommendation for an appetite stimulant.
Incorrect dialysis access site order: A resident with ESRD and dialysis dependence had orders to assess an AV fistula for bruit, thrill, and signs of complications, but the chart documented a dialysis port in the upper right chest instead. Staff interviews confirmed the resident did not have an accessible AV fistula, the incorrect order had been overlooked by multiple staff, and the record lacked an order to assess the port site.
Insulin pens in a med cart were found without open dates for three residents, including Novolog, Basaglar, glargine, and Lantus pens. An RN acknowledged insulin pens must be dated once opened to ensure they are not administered after expiration. Record review showed the residents had diabetes and active insulin orders, and the DON provided a policy stating multiple-dose insulin expires 28 days after opening and must be dated when first accessed.
Failure to Complete Ordered Lab Tests: Two residents did not have ordered lab work completed or documented as obtained. One resident on Keppra had an ordered Keppra level with unsuccessful draw attempts and delayed MD notification. Another resident with dementia and other diagnoses had ordered lipid panel, A1C, and B12 labs that were not obtained, with refusal and failed attempts documented but no MD notification. Staff reported ongoing lab service problems, including no consistent phlebotomist and difficulty processing labs.
Surveyors found that the facility did not maintain sufficient dietary staffing as outlined in its facility assessment, resulting in one Dietary Manager functioning as the sole cook for extended periods, working very long shifts with minimal support. During meal observations, only two dietary staff were present, and the cook was unable to honor a resident’s request for an additional food item due to time constraints while preparing all trays. Several residents reported that food quality had declined, meals were repetitive or late, and alternatives were not offered, which they linked to having only one cook. Review of staffing schedules confirmed a prolonged pattern of understaffing in the kitchen, including days with only one staff member and no separate cook scheduled.
An LPN was observed pre-pouring medications for multiple residents, handling pills with bare hands, and preparing medication cups in advance, resulting in missing prescribed medications for several residents. One resident and his sister reported incidents where the wrong medications were nearly administered. These actions were in direct violation of facility policy, which prohibits pre-pouring and requires medications to be prepared immediately prior to administration and not handled with bare hands.
An LPN was observed preparing medications by dispensing pills into her bare hands and placing them into medication cups, including picking up a dropped pill from the desk surface with bare hands. This practice was in direct violation of facility policy, which prohibits handling medications with hands, as confirmed by the DON and Nurse Consultant.
Two residents in an LTC facility did not receive showers or bed baths as per their preferences due to staffing challenges and inconsistent documentation. One resident, who required assistance, missed several scheduled bed baths, while another received fewer showers than scheduled, with no documented refusals. Staff interviews revealed inconsistencies in documentation practices, contributing to the deficiency.
The facility failed to dispose of expired insulin for two residents, as found during an inspection. Expired insulin vials and a pen were discovered on a medication cart and in a storage room, respectively. The facility's policy requires multi-dose vials to be discarded within 28 days, which was not followed.
The facility failed to label and date refrigerated and frozen food items properly, leading to potential contamination and spoilage. Observations revealed undated food items and water dripping onto food in the refrigerator. The Dietary Manager could not identify the water source, and the facility's storage guidelines were not followed.
A facility failed to document timely communication with a hospital prior to a resident's transfer. The resident, with COPD, cerebral infarction, and late-onset Alzheimer's, was hospitalized but lacked initial documentation of contact with the hospital ER. A late entry note was added later as a correction, indicating the family and ER were notified, which deviated from the facility's documentation policy.
A facility failed to properly handle a glucometer during blood glucose monitoring for two residents with type 2 diabetes. A QMA placed the glucometer directly on side tables without a barrier, contrary to facility policy. The glucometer was then returned to its case and the medication cart. Interviews revealed that the glucometer should have been placed on a paper towel to prevent cross-contamination.
The facility failed to update care plans with post-fall interventions for four residents reviewed for falls. A resident with a history of hemiplegia and dementia experienced multiple falls, including one requiring ER treatment, but care plans lacked immediate interventions. Another resident fell from a wheelchair without documented interventions, and a third resident's recent fall was not documented. A fourth resident reported falls without injury, but care plans lacked immediate interventions. Staff interviews revealed uncertainty about care plan updates, and the facility's policy was not effectively implemented.
The facility failed to ensure proper handling of clean and soiled linens. Staff members were observed carrying clean linens against their bodies and transporting soiled linens unbagged, contrary to the facility's infection control policy.
A facility failed to ensure a call light device was within reach for a resident with significant physical limitations. The resident's call light was repeatedly observed to be out of reach, forcing her to ask for help when staff entered her room. The DON acknowledged the issue and confirmed that the call light should not have been placed on the wall. The facility's policy required call lights to remain functional and within reach, which was not adhered to in this case.
A facility failed to ensure that pressure ulcer treatments were completed by qualified staff for a resident with a stage III pressure ulcer. Despite facility policy and state regulations, QMAs performed dressing changes beyond their scope of practice. Medical records and interviews confirmed that QMAs documented completing these tasks, which should have been performed by licensed nurses.
The facility failed to provide treatment to prevent further decrease in range of motion for a resident with a contracted left hand. Despite a referral for evaluation, no anti-contracture device was in place, and no treatment order was obtained. The care plan required range of motion exercises and repositioning, but these interventions were not documented or followed.
The facility failed to ensure the dish machine wash temperature met the required range, with observations showing a maximum of 80°F, below the manufacturer's guideline of 120-140°F. The Dietary Manager confirmed the discrepancy, despite logs inaccurately documenting compliant temperatures.
Failure to Notify Provider and Assess Worsening Pain After Fall
Penalty
Summary
The facility failed to ensure a resident’s change in condition after a fall was assessed and treated when the resident later developed worsening pain and was ultimately found to have a fractured right femur that required surgery. The resident had diagnoses including dementia, major depressive disorder, right femur fracture, and pain, and had a care plan identifying multiple fall risks, including impaired mobility, cognitive deficits, range of motion deficits, and dementia. A physician order was in place to assess pain and notify the medical provider if pain was new or worsening. After the resident was found on the floor beside the bed, staff documented no injuries and no complaints of pain, and the resident was returned to bed using a Hoyer lift. The facility notified the NP of the fall without injuries. However, the record showed repeated complaints of pain in the knees, legs, and all over during the days and nights that followed, including pain ratings up to 10 out of 10, and the record lacked documentation that a physician was notified when the pain worsened. A later note documented bruising and swelling to both knees, at which time the NP was notified and x-rays were ordered, but the record lacked documentation that the x-rays were completed. Additional late entries documented earlier complaints of increased pain during care with PRN pain medication given, but again there was no documentation that a physician was notified of the worsening pain after the fall. The resident was eventually sent to the hospital for uncontrolled pain and was later found to have a right femur fracture, L1-L4 compression deformities, and an L5 TP fracture. The resident underwent surgical fixation of the right femur fracture after the hospital transfer.
Missing Documentation for Resident and Representative Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents and their representatives participated in care plan meetings for 4 of 16 residents reviewed. The deficiency involved Residents 41, 40, 1, and 8, and the record review and interviews showed that care conference documentation was inconsistent or missing information about whether residents or their representatives were invited, attended, or declined to attend the meetings. Resident 41 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The resident’s brother, who was identified as the POA and responsible party, stated he attended a care plan meeting shortly after admission but had not known about or attended any meeting since then, and the resident could not remember having a meeting since that time. The record showed multiple care conferences, but several notes lacked documentation that the resident and/or brother/POA had been invited or were in attendance, and some lacked documentation explaining why they did not attend. The Social Services Director stated she sent letters to notify the brother/POA, was unsure why he had not attended, and acknowledged there was no consistency with progress notes about the meetings. The brother/POA later stated he could not remember receiving a letter about care plan meetings. Resident 40 was admitted with diagnoses including COPD, chronic pain, and atherosclerotic heart disease. The resident stated she had not been invited to any care plan meetings and said staff were welcome to meet in her room to discuss her needs. The record showed a care plan date had been entered, but it lacked documentation regarding the care plan meeting or whether the resident attended. The Social Services Director stated the review team went to the resident’s room for care plan meetings, that the resident was always invited, and that invitation letters were sent to family or the responsible party, but she did not have documentation for the actual care plan meetings. Resident 1 had diagnoses including depression, schizoaffective disorder, and fibromyalgia, and stated she did not remember having care plan meetings consistently. The record contained quarterly care conference notes that lacked documentation showing whether the resident or resident representative was invited or attended, although one later note documented the resident’s attendance. Resident 8 had diagnoses including dementia with mood disorder, major depressive disorder, and a right femur fracture, and stated she did not remember having care plan meetings regularly. The record showed several care conference notes that lacked documentation of invitation or attendance, while other notes documented attendance by the resident and, at times, the daughter. The Social Services Director stated she was unable to provide documentation that the resident and/or resident representatives had attended quarterly care plan meetings and said there were times she was unable to get the documentation completed on the computer or on paper.
Missing Psychotropic Medication Consents for New Start and Dose Increase
Penalty
Summary
The facility failed to ensure psychotropic medication consents were obtained for the initiation of or increase of psychotropic medications for 2 of 5 residents reviewed for unnecessary medications. One resident had diagnoses including depression, schizoaffective disorder, and fibromyalgia, and a quarterly MDS indicated moderate cognitive impairment and use of anti-psychotic and anti-depressant medications. A physician order directed duloxetine 20 mg daily, but the electronic health record lacked documentation that psychotropic informed consent had been obtained for the medication when it was initiated. During interview, the Clinical Consultant stated she had been misinformed about when psychotropic consents were needed and could not find documentation of consent for the duloxetine initiation. Another resident had diagnoses including major depressive disorder, recurrent, and generalized anxiety disorder, and a significant change MDS indicated no cognitive deficits and use of antidepressant medication. The resident’s record showed sertraline orders that were changed over time, including an increase to 150 mg daily for anxiety and depression, but the record lacked documentation of a consent form for that dosage increase. A psychiatry progress note stated the Psychiatrist discussed increased depression and anxiety with the IDT, and the IDT agreed the resident’s depression had increased and the sertraline dose should be increased. During interview, the Regional Clinical Consultant was unable to locate a consent form for the sertraline increase, and later provided the facility’s psychotropic medication consent policy stating consent shall be obtained for a new psychotropic medication or dosage increase.
Failure to Implement RD Recommendations for Resident Weight Loss
Penalty
Summary
The facility failed to ensure Registered Dietitian recommendations were addressed by the physician and that ordered interventions were implemented for a resident with documented weight loss. The resident had diagnoses including dementia, hypertension, and anorexia, and was noted to have a care plan for weight loss with interventions to monitor intake, notify the physician and dietitian of continued weight loss, and provide ordered supplements. During observation, the resident was seen drinking thin liquids from a two-handle cup and coughing frequently while drinking. The record showed the resident had been receiving thrive ice cream twice daily, but there was no documentation of a physician order or administration for the RD-recommended active liquid protein twice daily or Boost Breeze/Ensure Clear with breakfast. The resident’s weight history showed a decline from 240 pounds to 190.8 pounds over 6 months, including a 5.73% loss in 30 days. The record lacked documentation that the physician was notified of the continued weight loss. The RD later documented that oral intake was not adequate to meet estimated needs and recommended an appetite stimulant per MD preference, but there was no documentation that this recommendation was communicated to the physician. Facility staff acknowledged the recommendations had not been implemented and that the physician had not been notified.
Incorrect Dialysis Access Site Order
Penalty
Summary
The facility failed to ensure that the physician’s order for a resident receiving dialysis accurately matched the resident’s actual access site. The resident had diagnoses of end stage renal disease and dependence on renal dialysis, and the care plan indicated hemodialysis with monitoring of the shunt for bruit and thrill every shift. However, the nurse’s notes documented that the resident had a dialysis port in the upper right chest, and the record did not contain documentation of an order to assess that port site. The physician’s orders dated 7/17/25 directed staff to monitor the resident’s AV fistula site for bleeding, redness, swelling, warmth, bruit, and thrill every shift, with notification of the medical provider for complications or if bruit/thrill was negative. Staff interviews confirmed the mismatch: an RN stated she knew the resident did not have an AV fistula, and the Regional Clinical Consultant stated the incorrect order had been overlooked by several staff responsible for reviewing the resident’s orders. The consultant later stated the resident did have an AV fistula that was not accessible and used a dialysis port in the right upper chest for treatments.
Insulin Pens Stored Without Open Dates
Penalty
Summary
The facility failed to ensure insulin pens stored in the medication cart were labeled with an open date. During observation of the North hall medication cart with RN 6, insulin pens for Resident 37, Resident 12, and Resident 34 were found without any date opened recorded on the label or the pen. The observed insulin pens included Novolog insulin pens and a Basaglar insulin pen for Resident 37, a glargine insulin pen for Resident 12, and a Lantus insulin pen for Resident 34. RN 6 acknowledged that insulin pens must be dated once opened to ensure they are not administered after the expiration date. Record review showed Resident 37 had a diagnosis of diabetes and a physician order for Novolog FlexPen U-100 Insulin, 13 units subcutaneously with meals; the current physician orders dated 3/1/26 did not include an order for Basaglar insulin. Resident 12 had a diagnosis of diabetes and a current order for glargine insulin 100 unit/mL, 13 units subcutaneously at bedtime. Resident 34 had a diagnosis of diabetes and a current order for Lantus Solostar U-100 Insulin, 30 units subcutaneously twice a day. The DON provided the facility policy titled Medication expiration, dated 10/2014, which stated multiple dose injections such as insulin expire 28 days after opening unless otherwise noted by the manufacturer and that staff shall date the label of any multi-use vial when first accessed.
Failure to Complete Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure laboratory services were completed as ordered for two residents. One resident had a history of seizures and was receiving Keppra 500 mg twice daily. After a pharmacy recommendation to check a Keppra level, the physician ordered the test, but the record did not show that the level was obtained. The lab order tracking form showed unsuccessful draw attempts on the left hand and left antecubital area, but the progress notes did not document those failed attempts or that the physician was notified until several days later. The second resident had diagnoses including osteomyelitis, dementia, and a personal history of pulmonary embolism, and had severe cognitive impairment with dependence for showers and toileting. Pharmacy recommendations were made to check a fasting lipid panel, A1C, and B12 level to monitor medication safety and effectiveness. The physician agreed and ordered the labs, but the record lacked documentation that the tests were obtained. The lab tracking form showed the resident refused one draw, another attempt could not be made because the resident had already eaten, and a later attempt in the left hand and left antecubital area was unsuccessful, with no documentation that the physician was notified of the refusal or failed attempts. During interviews, facility staff stated there were ongoing problems with lab services. The ADON said the resident’s veins were difficult due to cancer treatments and that blood could not be obtained. RN 6 stated the resident did have a port, but it was not accessible for nurses at the facility. The clinical consultant stated the facility had lost its lab contract in November 2025, had not had a consistent phlebotomist since then, had to transport labs to the hospital for processing, and did not have a nurse available who could draw labs in a timely manner. The consultant also stated the facility had a system failure related to lab services.
Inadequate Dietary Staffing Leading to Poor Food Quality and Service
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient food and nutrition services staff as outlined in its own facility assessment, which called for a director and three food and nutrition services staff. Surveyors reviewed a confidential statement indicating that the food from the kitchen was described as disgusting and that there were not enough kitchen workers. During a lunch observation, only two dietary staff were present: the Dietary Manager, who was also the cook, and a Dietary Aide. The Dietary Manager was the only person plating food for both the dining room and hall trays and was unable to provide an additional food item requested by a resident, stating she did not have time because she needed to prepare all the hall trays. Multiple residents reported concerns about food quality and lack of alternatives, which they attributed to insufficient kitchen staffing. One resident stated that the food had gone downhill, was repetitive, and not worth eating, and commented that there was only one cook who could not manage all the work. Another resident reported that the food was terrible and that no alternatives were offered because there was only one cook who did not have time to prepare other options. A third resident reported that meals were often late and that food quality had declined, acknowledging that there was only so much one person could do. Interviews and schedule reviews showed that the Dietary Manager had effectively been working as the only cook for an extended period. The Administrator stated the facility should have a full-time Dietary Manager, day cook, evening cook, and dishwasher, and that other non-dietary staff could help in the kitchen if needed. The Dietary Manager reported she had been performing manager duties since August 2025, had been prepping, cooking, and cleaning up all meals daily, working approximately 14 hours a day, 7 days a week, and had worked over 30 days without a day off. She also reported not being trained on the computer system for ordering food and lacking time to properly clean the kitchen or begin ServSafe certification. Review of dietary schedules over several weeks showed repeated days with only two staff in the kitchen, the Dietary Manager consistently working 13–14 hour shifts, and at least one day with only one staff member in the kitchen and no cook scheduled, demonstrating a sustained pattern of inadequate staffing relative to the facility’s own assessment.
Failure to Ensure Safe and Accurate Medication Administration
Penalty
Summary
The facility failed to ensure safe and accurate medication administration for four residents, as observed during a random medication pass. An LPN was seen preparing multiple residents' medications in advance by dispensing pills from medication cards into her bare hands and placing them into medication cups, which were then stacked and labeled with residents' initials. The LPN dropped a pill onto the desk, picked it up with her bare hands, and placed it back into a medication cup. The medications were prepared ahead of time for later administration, and several medication cups were missing required medications according to the residents' electronic Medication Administration Records (eMARs). Further review revealed that the LPN had not included all prescribed medications in the cups for several residents. For example, one resident's cup was missing clonidine, another was missing magnesium oxide, primidone, and sertraline, and a third was missing atorvastatin, buspirone, gabapentin, pramipexole, sertraline, and tizanidine. Additionally, a resident reported that the LPN had attempted to give him the wrong medications on two separate occasions in the dining room, which was corroborated by his sister. The LPN admitted to setting down the wrong medication cups but claimed to have caught the errors before administration. The facility's policy, revised in 2017, explicitly stated that medications should never be pre-poured, should not be touched with bare hands, and must be prepared just prior to administration. The policy also required staff to observe residents taking their medications. Despite this, the LPN pre-poured medications for multiple residents, handled pills with bare hands, and failed to ensure the correct medications were prepared and administered as ordered.
Improper Medication Handling During Medication Pass
Penalty
Summary
During a random observation, an LPN was seen preparing medications at the nurses' station by dispensing pills from medication cards directly into her bare hands and then placing them into medication cups. The LPN also picked up a pill that had fallen onto the desk surface with her bare hands and placed it into a medication cup. When questioned, the LPN stated she was unaware this was an issue after washing her hands. Facility policy, as provided by the DON, clearly states that medications should never be touched with hands during administration. The Nurse Consultant confirmed that at no time should medications be handled with bare hands.
Failure to Provide Scheduled Showers and Bed Baths
Penalty
Summary
The facility failed to ensure that residents were provided with showers or bed baths according to their preferences, as evidenced by the cases of two residents. Resident 41, who was cognitively intact and required assistance with activities of daily living, expressed that he preferred to receive bed baths twice a week in the evenings. However, due to staffing challenges, he often did not receive these baths as scheduled, with documentation showing missed baths on several occasions. Interviews with staff confirmed the difficulty in completing all tasks due to insufficient staffing, and the facility was unable to provide documentation to support that the baths were administered as scheduled. Similarly, Resident 40, who was also cognitively intact and required assistance with bathing, reported not receiving regular showers as per his preference for two showers per week in the evenings. The facility's records indicated that the resident received fewer showers than scheduled, and there was a lack of documentation regarding any refusals of care. Interviews with CNAs and the DON revealed inconsistencies in documentation practices, with some staff unaware of any refusals by the resident, while others mentioned the use of behavior sheets for refusals, which were not consistently documented in the medical record. The facility's failure to adhere to residents' preferences for personal hygiene care, as well as the lack of consistent documentation and communication among staff, contributed to the deficiency. The facility's policy on resident rights emphasized the importance of treating residents with respect and dignity, yet the documentation and interviews highlighted a gap in fulfilling these rights, particularly in maintaining the residents' quality of life through their preferred care routines.
Expired Medications Not Disposed of Properly
Penalty
Summary
The facility failed to ensure the proper disposal of expired medications, specifically insulin, for two residents. During an inspection, surveyors found two expired insulin vials on the south hall medication cart, which were labeled for a resident with type 2 diabetes mellitus with hyperglycemia. The insulin vials had an open date of over 30 days prior, exceeding the recommended usage period. A Qualified Medication Aide confirmed that the insulin should have been discarded after 30 days of being opened. Additionally, an expired insulin pen was found in the north hall medication storage room, labeled for another resident with type 2 diabetes mellitus without complications. The insulin pen had an open date of over 28 days prior, and a Qualified Medication Aide was unsure why it was not discarded. The facility's policy, provided by the Corporate Nurse Consultant, indicated that multi-dose vials like insulin should be discarded within 28 days unless specified otherwise by the manufacturer. These findings indicate a failure to adhere to the facility's medication expiration policy.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to properly label and date refrigerated and frozen food items, which is necessary to ensure they are used by their use-by date, frozen, or discarded appropriately. During an initial kitchen observation, tomatoes and lettuce in the main refrigerator were found with an opened date of 2/24, and water was observed dripping onto a covered container of chicken noodle soup. Additionally, the bottom of the refrigerator had water, causing boxed food items to become wet. In the freezer, several items, including tater tots, pie shells, cakes, and pies, were found undated, indicating a lack of adherence to proper food storage guidelines. Further observations revealed standing water on the top shelf of sealed food items in the refrigerator, which spilled onto the floor when moved. The Dietary Manager was unable to identify the source of the water. The facility's storage guidelines, provided by the Administrator, indicated specific storage durations for various food items, which were not followed. This lack of compliance with food storage standards poses a risk of food contamination and spoilage.
Failure to Document Timely Hospital Transfer Communication
Penalty
Summary
The facility failed to ensure timely documentation of contact with the hospital prior to the transfer of a resident, identified as Resident 31, who was hospitalized. The resident's medical history included chronic obstructive pulmonary disease (COPD), cerebral infarction, and late-onset Alzheimer's disease. The resident was noted to have a moderate cognitive deficit, was totally dependent on all activities of daily living, and required continuous oxygen. The resident was hospitalized from March 9 to March 13, 2025, but the initial review of the record lacked documentation of the facility's contact with the hospital emergency room to provide a report of the transfer. A follow-up review revealed a late entry progress note dated March 18, 2025, for the transfer date of March 9, 2025, indicating that the family and emergency room had been notified. This note was added as a plan of correction after it was discovered that no note had been written at the time of the transfer. The facility's policy, provided by the Administrator, required nurse's notes to be written on each resident, addressing the resident's conditions and any pertinent change in condition, and to document significant information. The failure to document the transfer in a timely manner was a deviation from this policy.
Improper Handling of Glucometer During Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper handling of the glucometer during blood glucose monitoring for two residents. During observations, a Qualified Medication Aide (QMA) placed the glucometer directly onto the side tables of Residents 42 and 35 without using a barrier, such as a paper towel, as required by the facility's policy. This action was observed during two separate blood glucose monitoring opportunities. The glucometer was then returned to a resident-specific black case and placed back in the medication cart without proper barrier protection. Resident 42 has a diagnosis of type 2 diabetes mellitus with hyperglycemia, while Resident 35 has type 2 diabetes mellitus without complications. During an interview, QMA 7 mentioned that the night shift nurses clean the glucometers, and she also cleans them at the end of her shift. However, QMA 10 later indicated that a paper towel should be placed under the glucometer to prevent cross-contamination, which was not done in these instances. The facility's policy, provided by the Corporate Nurse Consultant, clearly states that a clean paper towel should be used as a barrier when placing the glucometer on a surface.
Failure to Update Care Plans with Post-Fall Interventions
Penalty
Summary
The facility failed to update care plans with post-fall interventions for four residents reviewed for falls. Resident A, who has a history of hemiplegia, vascular dementia, and aphasia, experienced multiple falls, including one that resulted in a head laceration requiring emergency room treatment. Despite these incidents, the care plans lacked evidence of immediate post-fall interventions and did not document the level of assistance required for transfers and mobility. Interventions such as moving the resident's room closer to the nurses' station and using alarms were noted, but there was no documentation of monitoring or specific interventions related to the root causes of the falls. Resident C's medical record indicated a fall from a wheelchair, but the care plan lacked evidence of immediate post-fall interventions. Although interventions like anti-rollbacks for the wheelchair and frequent reminders were documented, there was no documentation of interventions related to the root causes of the falls. Similarly, Resident H's record lacked documentation of a recent fall, and the care plan did not include immediate post-fall interventions, despite the resident being at risk for falls. Resident K, who reported three falls without injury, had a care plan indicating a risk for falls, but the record lacked documentation of immediate post-fall interventions. Interviews with facility staff revealed uncertainty about who was responsible for updating care plans, and the facility's policy on care plan development and review was not effectively implemented. The interdisciplinary team was supposed to update care plans after each fall, but this was not consistently done, leading to deficiencies in the care provided to residents at risk of falls.
Improper Handling of Clean and Soiled Linens
Penalty
Summary
The facility failed to ensure proper handling of clean and soiled linens during multiple observations. Certified Nursing Assistant (CNA) 21 was observed on several occasions retrieving clean linens from the linen closet and transporting them against her body to various locations, including resident rooms and a shower room. Similarly, Employee 3 was seen carrying soiled linens unbagged against her body while wearing gloves, and indicated she needed to take the linens to the hopper. These actions were contrary to the facility's policy, which mandates that clean linens should not be carried against the body and soiled linens should be placed in a container before being transported in the hallway. Interviews with staff members, including Employee 8 and CNA 22, confirmed that the proper procedure for handling linens was not followed. Employee 8 indicated that staff were not supposed to carry linens against their body, and soiled linens were to be transported in a plastic bag. CNA 22 also confirmed that dirty linens should be bagged before being taken to the hopper room and that clean linens should be held away from the body. The facility's policy, provided by the Regional Nurse Consultant, clearly stated that linens should be handled in a manner to prevent the spread of infection, including not carrying clean linens against the body and placing soiled linens in a container before transporting them in the hallway.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a call light device was within reach for a resident, leading to a deficiency. On multiple occasions, the resident's call light was observed to be draped on an outlet against the wall and out of reach. The resident, who had significant physical limitations and required assistance for turning and repositioning in bed, indicated that staff had recently stopped providing her with a call light, forcing her to ask for help when staff entered her room. The resident's medical history included right and left knee contractures, muscle weakness, stiffness of the left hand, and gastrostomy status. She was cognitively intact but had functional limitations in both upper and lower extremities and moderately impaired vision. During an interview, the DON acknowledged that the resident did not use her call light often and was not ordered to have a soft touch call light. However, upon observation, the DON confirmed that the call light should not have been placed on the wall and subsequently placed it within the resident's reach. The facility's policy, dated 10/2014, stated that call lights must remain functional and within reach of each resident, and must not be disabled or removed from the resident's reach. Despite this policy, the call light was repeatedly found out of reach, indicating a failure to accommodate the resident's needs and preferences.
Failure to Ensure Qualified Staff Perform Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed by qualified staff and that proper standards of practice were followed for a resident with a stage III pressure ulcer. Resident 29, who had a history of stage IV pressure ulcers and was diagnosed with Type 2 diabetes mellitus and chronic obstructive pulmonary disease, reported having an open area on his bottom for a few months. Interviews revealed that Qualified Medication Aides (QMAs) were performing dressing changes on the resident's pressure ulcer, which is beyond their scope of practice as per facility policy and state regulations. The resident's medical records indicated that the pressure ulcer was being treated with specific physician-ordered dressings. However, documentation showed that QMAs were completing these dressing changes on multiple occasions, despite the facility's policy that only licensed nurses should perform such tasks. The Director of Nursing and other staff members confirmed that QMAs are not permitted to perform dressing changes on wounds greater than stage I, and acknowledged that QMAs had been signing off on these tasks in the Medication Administration Records (MARs). The facility's policies, including the Qualified Medication Aide Scope of Practice and Job Description, explicitly state that QMAs are not allowed to administer treatments for advanced skin conditions, including stage II, III, and IV pressure ulcers. Despite this, the MARs for December 2023, January 2024, and February 2024 showed multiple instances where QMAs documented completing dressing changes for Resident 29's stage III pressure ulcer. The Regional Nurse Consultant and the Director of Nursing were aware of this issue and indicated that the QMAs would be educated on their scope of practice.
Failure to Prevent Decrease in Range of Motion
Penalty
Summary
The facility failed to provide treatment to prevent further decrease in range of motion for a resident with a contracted left hand. During multiple observations, the resident was seen sitting in a wheelchair with the left hand contracted in a fist position and no anti-contracture device in place. Interviews with the Director of Nursing (DON) and the Certified Occupational Therapy Assistant (COTA) revealed that although a referral for evaluation was made, the evaluation had not been completed, and no treatment order had been obtained. The COTA acknowledged receiving the referral but had not yet conducted the evaluation. The Regional Nurse Consultant also confirmed that an order for evaluation was discussed but not obtained. The resident's medical record indicated diagnoses including hemiplegia, hemiparesis, muscle weakness, and other conditions. The care plan noted the resident was at risk for complications related to hemiplegia/hemiparesis and required range of motion exercises and repositioning of affected limbs. However, there was no documentation of orders for range of motion or prevention of contractures, and the care plan interventions were not being followed. The facility's policy on joint mobility screening outlined procedures for identifying residents at risk for contractures and recommended interventions, but these were not implemented for the resident in question.
Dish Machine Temperature Non-Compliance
Penalty
Summary
The facility failed to ensure the wash temperature of the chemical sanitizing dish machine met the required temperature during a kitchen observation. During the initial kitchen tour, the dish machine temperature dial indicated a top temperature of 80 degrees Fahrenheit during the wash cycle, which was below the required range of 120-140 degrees Fahrenheit as per the manufacturer's guidelines. Four separate wash cycles were attempted, none of which reached a temperature higher than 80 degrees Fahrenheit. The Dietary Manager confirmed this with a manual thermometer and acknowledged that the minimum temperature should be between 100 and 120 degrees Fahrenheit. Despite this, the dish machine temperature logs for February 2024 inaccurately documented the wash temperature as 100 degrees Fahrenheit for all days of the month, indicating a discrepancy between recorded and actual temperatures.
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What surveyors actually found near you
We read the 184 citations issued within 25 miles in the last 12 months — including the 4 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Terre Haute
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Village Health & Rehab | 1.1 mi | ★★★★★ | 1 | 0 |
| Springhill Village | 1.7 mi | ★★★★★ | 5 | 0 |
| Southwood Healthcare Center | 1.9 mi | ★★★★★ | 24 | 2 |
| Majestic Care Of Deming Park | 3.3 mi | ★★★★★ | 4 | 2 |
| Harrison's Crossing Health Campus | 3.5 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.