Below 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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westy Community Care Home during CMS and state inspections, most recent first.
The facility did not employ a full-time Certified Dietary Manager for its 31 residents, risking inadequate nutrition. Observations showed kitchen staff preparing meals without a Certified Dietary Manager present. One staff member was off, and another was still obtaining certification. The facility's policy required a Certified Dietary Manager credential, which was not fulfilled.
The facility failed to submit accurate staffing information through the PBJ, as required by CMS, indicating a lack of licensed nurse coverage on multiple days. However, a review showed that a licensed nurse was on duty 24/7. Administrative Staff A noted that payroll data was sent to a corporate office for submission, leading to inaccuracies. This failure placed residents at risk for inadequate staffing.
The facility did not ensure that the designated Infection Preventionist (IP) completed the required specialized training in infection prevention and control. Administrative Nurse E, responsible for the IPCP, was in the process of taking the necessary class and confirmed she was not certified. The facility's policy required the IP to have relevant professional training and certification, work part-time at the facility, and participate in the QAA committee. This deficiency placed 31 residents at risk for inadequate infection identification and treatment.
The facility did not follow CDC guidance for pneumococcal vaccinations, failing to offer or document informed declinations or contraindications for five residents. The facility's policy required documentation of vaccine administration or refusal, but records lacked evidence of consent or informed declination. An Administrative Nurse admitted the vaccine was only offered to new residents, contrary to policy, placing residents at risk of pneumococcal disease.
A resident with severe cognitive impairment and pressure ulcers was found with a malfunctioning ROHO-type cushion in their recliner, which had lost air and gone flat. Despite a care plan that included pressure-reducing devices, the nursing staff failed to ensure the cushion was properly inflated, compromising the resident's pressure ulcer care and placing them at risk for delayed healing.
A facility failed to ensure a Consultant Pharmacist identified and reported missed doses of insulin and Parkinson's medication for a resident with multiple diagnoses, including diabetes and Parkinson's disease. The resident's Medication Administration Records for several months showed missed doses, which were not communicated to the physician or Director of Nursing, placing the resident at risk for physical decline.
A resident with Parkinson's disease and diabetes did not receive medications as ordered, with missing documentation for Sinemet and insulin on multiple occasions. The facility's policy required accurate documentation, but observations and staff interviews revealed inconsistencies, risking ineffective medication management.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer. Despite having an EBP sign and PPE available, a nurse did not wear a gown during a dressing change, contrary to the facility's policy. This oversight was acknowledged by the nurse and confirmed by an administrative nurse, placing the resident at risk for facility-acquired infections.
Lack of Full-Time Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager for its 31 residents, which placed them at risk of inadequate nutrition. During the survey, it was observed that the kitchen staff was preparing meals without the presence of a Certified Dietary Manager. On one occasion, the Dietary Staff CC mentioned that the Dietary Manager was off for the day but would return during the survey period. Another staff member, Dietary Staff BB, reported that he was in the process of obtaining a certified dietary manager course. The facility's policy from 2020 indicated that the Dining Service Manager should have a Certified Dietary Manager credential, but this standard was not met.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year 2023 Quarter 4 and Fiscal Year 2024 Quarters 1, 2, and 3 indicated that the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days. Specifically, there were 11 days in FY 2023 Quarter 4, 5 days in FY 2024 Quarter 1, 25 days in Quarter 2, and 5 days in Quarter 3 where the facility reportedly lacked licensed nurse coverage. However, a review of the facility's licensed nurse data for the dates listed on the PBJ revealed that a licensed nurse was on duty 24 hours a day, seven days a week. On September 18, 2024, an observation confirmed the presence of a licensed nurse on duty in the facility. Administrative Staff A reported that the facility sent payroll information to a corporate office, which then submitted it to the PBJ. She stated that there was always a nurse on duty, but the information submitted was inaccurate. The facility's policy on the Mandatory Submission of Uniform Format Staffing Information, dated September 18, 2024, documented the requirement to electronically submit complete and accurate direct care staffing information to CMS. The failure to submit accurate PBJ data placed the residents at risk for unidentified and ongoing inadequate staffing.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the staff member designated as the Infection Preventionist (IP) for the Infection Prevention and Control Program (IPCP) completed the necessary specialized training in infection prevention and control. This deficiency was identified during an interview and record review, where Administrative Nurse E, who was responsible for the IPCP, admitted to being in the process of taking the required class and confirmed that she was not certified. The facility's Infection Control Policy, dated 03/13/23, stipulated that the IP must have primary professional training in relevant fields and be qualified by education, training, experience, or certification. Additionally, the policy required the IP to work at least part-time at the facility, complete specialized training, and participate in the Quality Assurance Performance Improvement (QAA) committee regularly. The lack of certification for the designated IP placed the 31 residents at risk for inadequate identification and treatment of infections.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adhere to the latest guidance from the Centers for Disease Control and Prevention (CDC) regarding the administration of pneumococcal vaccinations. Specifically, the facility did not offer or administer the pneumococcal PCV20 vaccine to five residents, nor did they obtain informed declinations or physician-documented contraindications for these residents. This oversight was identified through a review of clinical medical records, which lacked evidence of consent or informed declination for the vaccine. The facility's policy, dated January 31, 2024, stated that vaccines would be administered by qualified personnel without the need for individual physician orders, and that documentation should include whether the resident received the vaccine or refused it due to medical contraindications or personal choice. During an interview, the Administrative Nurse revealed that the facility only offered the PCV20 vaccine to new residents and did not maintain documentation of it being offered or declined. This practice was inconsistent with the facility's policy, which required that each resident be provided with current information from the CDC and FDA regarding the benefits and risks of the vaccine. The failure to offer the pneumococcal PCV20 vaccinations as per CDC recommendations placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.
Failure to Maintain Pressure-Reducing Devices
Penalty
Summary
The facility failed to ensure that pressure-reducing devices functioned correctly for a resident with pressure ulcers, leading to a deficiency in care. The resident, who had severe cognitive impairment and a history of pressure ulcers, was observed sitting in a recliner with a ROHO-type cushion that had lost air and gone flat. This malfunctioning cushion was intended to relieve pressure on the resident's coccyx area, where they had a Stage 2 pressure ulcer. Despite having a care plan that included the use of pressure-reducing devices and regular dressing changes, the cushion's failure to maintain proper inflation compromised the resident's pressure ulcer care. The resident's medical records indicated a history of cognitive impairment, urinary incontinence, and pressure ulcers, with a care plan that included the use of an air mattress and pressure-relieving cushions. However, the nursing staff did not ensure the cushion was properly inflated, as they were responsible for checking its function. This oversight placed the resident at risk for delayed healing or worsening of the existing pressure ulcer, as the cushion was not providing the necessary pressure relief. The facility's wound management policy emphasized the importance of controlling causative factors such as pressure, but the failure to maintain the cushion's functionality demonstrated a lapse in adhering to these guidelines.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported staff's failure to follow physician's orders for administering insulin and medications for Parkinson's disease to a resident. The resident, identified as R2, had multiple diagnoses including Parkinson's disease, diabetes mellitus type two, dementia, hypertension, delusional disorder, and anxiety. The resident's care plan required staff to administer medications as ordered and monitor their effectiveness. However, the Medication Administration Records for July, August, and September 2024 showed missed doses of Sinemet and insulin, which were not identified or reported by the CP. Observations and interviews revealed that the CP did not communicate these medication administration issues to the responsible physician or the Director of Nursing. The facility's policy required the CP to review medication regimens monthly and document findings in the clinical record, but this was not done. The failure to administer the prescribed medications placed the resident at risk for physical decline and an ineffective medication regimen.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for a resident, identified as R2, who was receiving treatment for Parkinson's disease and diabetes mellitus type two. The resident's medical records indicated that Sinemet, a medication for Parkinson's disease, was not documented as administered on several occasions in July, August, and September 2024. Additionally, there were instances where insulin, prescribed for diabetes management, was not documented as administered on specific dates in July, August, and September 2024. These omissions in medication administration documentation were observed despite the facility's policy requiring accurate and timely documentation of all medication administration. The resident, R2, had a complex medical history including Parkinson's disease, diabetes mellitus type two, dementia, hypertension, delusional disorder, and anxiety. The resident's care plan directed staff to administer medications as ordered and to monitor and document side effects and effectiveness. However, the lack of documentation for the administration of Sinemet and insulin suggests a failure to adhere to these directives. Observations and interviews with facility staff revealed inconsistencies in the administration and documentation process, placing the resident at risk for unnecessary medication side effects and an ineffective medication regimen.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were properly implemented for a resident with an ongoing pressure ulcer requiring dressing changes. During an observation, it was noted that the resident's room had an EBP sign and a supply tote with personal protective equipment (PPE) such as gloves, gowns, and eye protection shields. However, a Licensed Nurse (LN) did not adhere to the EBP protocol during a dressing change. The nurse washed her hands and wore gloves but did not don a gown while assisting the resident into the bathroom and during the dressing change. The nurse acknowledged the oversight of not wearing a gown, which was confirmed by an Administrative Nurse. The facility's EBP policy, aligned with CDC recommendations, mandates the use of targeted PPE during high-contact care activities to prevent healthcare-acquired infections. The failure to use a gown during the dressing change placed the resident at risk for facility-acquired infections, as the EBP was not followed as per the facility's policy.
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Illustrative
What surveyors actually found near you
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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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westmoreland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Valley Vista | 8.1 mi | ★★★★★ | 0 | 0 |
| Meadowlark Hills | 14.2 mi | ★★★★★ | 0 | 0 |
| Onaga Operator, Llc | 15.3 mi | ★★★★★ | 10 | 0 |
| Via Christi Village Manhattan, Inc | 15.4 mi | ★★★★★ | 8 | 1 |
| Stoneybrook Retirement Community | 16.8 mi | ★★★★★ | 9 | 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.