Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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 failed to provide a full-time certified dietary manager for residents receiving meals from the kitchen. Dietary staff prepared breakfast, and staff later stated the person serving as dietary manager had only been in the role for one month and was not certified. Administration confirmed the prior dietary manager had quit about a month earlier and that the current staff member would be enrolled in CDM classes soon. The facility policy required a qualified Dietary Supervisor/CDM with state-approved certification.
Staff left the memory care kitchenette/dining area unattended while cognitively impaired, independently mobile residents were present, and an unlocked cabinet contained a spray bottle of disinfectant cleaner. A resident was able to enter the kitchenette, pour coffee from a carafe, and drink it, while an electric griddle remained warm and later was left on low with scrambled eggs on it when CNA M stepped away. Administrative Nurse D verified chemicals should be locked up, the area should not be left unattended, and coffee should not be accessible for residents to pour themselves.
Expired medications were found in an emergency kit stored in the med room, including multiple antibiotics, epinephrine, naloxone, warfarin, potassium chloride, clonidine, lisinopril, furosemide, phytonadione, prednisone, and fluconazole. An ADON verified the expired stock and stated the pharmacy was responsible for periodic checks and removal of expired meds, but was unsure when the kit had last been inventoried.
A resident's dignity was not protected when an LPN wheeled the resident from the dining room to the medication cart in the commons area and checked the resident's blood sugar with a glucometer while two residents were eating breakfast and staff and a visitor were within view. The facility's policy stated care should be provided in a manner and environment that maintains dignity and that staff should avoid practices that could be considered demeaning.
A resident with edema, severe cognitive impairment, and oxygen use developed labored breathing, fatigue, wheezing, and an increased O2 requirement to 4 L by mask/cannula. The record lacked evidence that the MD and family were notified of the change in condition, and an LPN stated she faxed the MD but did not document it and could not recall whether the family was informed.
A facility failed to document appropriate indication and physician rationale for continued antipsychotic use for two residents. One resident with dementia and Parkinson’s disease received Zyprexa for agitation, and another resident with psychotic disorder and severe cognitive impairment received risperidone for vascular dementia; in both cases, the record lacked evidence of unsuccessful nonpharmacological interventions and risk-versus-benefit documentation. An admin nurse verified the medications were being given and stated the facility would contact the physician for appropriate documentation.
Failure to provide transfer, bed hold, and LTCO notifications: A resident was transferred to the hospital with return anticipated, but the facility could not produce the written transfer notice or bed hold policy for the resident or representative. SS and admin staff said they had been discussing who would send the Ombudsman and family notifications, but no notifications were provided, and admin staff verified the LTCO notice was not sent.
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 Certified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for the 31 residents who received meals from the kitchen. Observation on 07/26/2026 at 08:35 AM showed dietary staff preparing the breakfast meal. On 07/27/2026 at 09:30 AM, Dietary Staff BB stated she was the certified dietary manager and had been in the position for one month, and she reported the facility had six residents on a pureed diet. On 07/28/2026 at 01:00 PM, Administrative Staff A verified that Dietary Staff BB was not certified and stated the previous dietary manager had quit a month earlier, that Dietary Staff BB had started in the role, and that she would be enrolled in Certified Dietary Manager classes soon. The facility policy dated 06/26/2026 stated the facility would employ a qualified Dietary Supervisor/Certified Dietary Manager responsible for organizing, directing, staffing, monitoring, and evaluating all food service operations, and that the Dietary Supervisor shall possess successful completion of a state-approved Certified Dietary Manager certification program.
Unsecured chemicals and unattended hot items in memory care kitchenette
Penalty
Summary
The facility failed to ensure an environment free from accident hazards when staff did not secure chemicals and left the memory care kitchenette and dining area unattended while cognitively impaired, independently mobile residents were present. On 07/26/2026 at 07:55 AM, observation showed an unlocked kitchenette door with a 24-ounce spray bottle of One Step Disinfectant Cleaner stored in a cabinet, despite the warning to keep it out of reach of children. During the same observation, R23 was in the unlocked kitchenette without staff present, opened a coffee carafe, poured coffee into his cup, and drank it. An electric cooking griddle, approximately 15 inches by 20 inches, was also observed with the lid on, turned off, still warm to the touch, and able to be readily turned on with a dial. The kitchenette and dining room were left unattended for approximately eight minutes while one staff member was showering a resident and another aide went to the main facility commons area. On 07/27/2026 at 07:35 AM, CNA M assisted residents in the memory care unit with breakfast, then left the kitchenette/dining room at 07:45 AM to get another resident, leaving the area unattended for approximately two minutes. During that time, two residents were eating breakfast and one was drinking coffee, while the kitchenette remained unattended and the electric cooking griddle was open with scrambled eggs on it and the temperature dial turned to low. Administrative Nurse D later verified that the kitchenette cabinet storage door should be closed and locked, chemicals should be out of residents’ reach, the kitchenette/dining rooms should not be left unattended while cognitively impaired residents are present, the griddle should be turned off and not in use, and coffee should not be accessible for residents to pour their own drinks, especially hot liquids. The facility’s policies also stated that hazardous chemicals are to be locked and that access to coffee and other hot liquids should be supervised.
Expired medications found in emergency kit
Penalty
Summary
The facility failed to store medications and biologicals adequately when staff did not discard expired stock medication from the emergency kit in the medication room. On 07/28/2026 at 1:30 PM, observation of the emergency kit showed an expiration date of 05/19/2026 and multiple expired items, including ceftriaxone 1 gram bottles, epinephrine 50 mg bottles, lidocaine 50 mg bottles, naloxone hydrochloride 2 mg injection pen, glucagon emergency kit components, amoxicillin 500 mg tablets, amoxicillin and clavulanate potassium 500-125 mg tablets, cefdinir 300 mg tablets, ciprofloxacin 250 mg tablets, cephalexin 250 mg capsules, nitrofurantoin 100 mg tablets, doxycycline 100 mg tablets, warfarin 1 mg tablets, potassium chloride tablets, clonidine 0.1 mg tablets, lisinopril 10 mg tablets, furosemide 20 mg tablets, phytonadione 5 mg tablets, prednisone 5 mg tablets, and fluconazole 150 mg tablets. At 1:40 PM, Administrative Nurse D verified the expired emergency kit medications and stated the pharmacy was supposed to check the kit periodically for expired medications and discard them. The nurse was not sure when the pharmacy had last checked the kit and said he would call the pharmacy that day to have a new emergency kit brought in and the expired medications removed. The facility’s Emergency Pharmacy Services and Emergency Drug kits policy, dated 07/26/2026, stated emergency kits are inventoried by the pharmacy provider at least every 30 days for completeness and expiration dating, with the inventory date noted on the outside of the kit.
Dignity Violation During Blood Sugar Check
Penalty
Summary
The facility failed to provide care for Resident 7 in a manner that protected and promoted dignity. On 07/27/2026 at 07:52 AM, R7 was observed sitting at the dining room table when Licensed Nurse G wheeled the resident to the medication cart in the commons area adjacent to the dining room and obtained a blood sugar reading from R7's right index finger using a glucometer. During this observation, two residents were eating breakfast in the dining room, and staff and a visitor were present in the dining room and commons area within view. On 07/27/2026 at 10:00 AM, Administrative Nurse D stated staff should not check residents' blood sugar readings in the dining room and should take residents to their room or another private area. The facility's Right to Dignity policy stated the facility would promote care in an environment that maintains and enhances each resident's dignity and respect and that staff would refrain from any practice that could be considered demeaning to a resident.
Failure to Notify Physician and Family of Change in Respiratory Status
Penalty
Summary
The facility failed to notify Resident 36’s family when the resident had a change in condition. Resident 36 had a diagnosis of localized edema, severely impaired cognition with a BIMS score of 2, required partial to moderate staff assistance with most ADLs, and used oxygen therapy. The care plan directed staff to administer medications as ordered, monitor for side effects, report lab results to the physician, and monitor for signs and symptoms of respiratory distress and report as needed. On 04/17/2026, nursing documentation noted the resident was being treated for fluid overload, was improving, had diminished but clear lung sounds, and needed less oxygen, with an oxygen saturation of 92% on room air when sitting upright. On 04/19/2026, the resident developed labored breathing, fatigue, and slight wheezing in both lungs, and was placed on four liters of oxygen by face mask and later by nasal cannula after a breathing treatment. The record lacked evidence that the physician and family were informed of the increased oxygen need on 04/19/2026. A licensed nurse stated she faxed the physician but did not document it and did not remember whether the family was notified, while an administrative nurse verified there was no documentation that the physician was notified and that the physician’s office had received a fax from the following day but not from 04/19/2026.
Unnecessary Antipsychotic Use Without Required Documentation
Penalty
Summary
The facility failed to ensure appropriate indication and documented physician rationale for continued antipsychotic use for two residents. One resident had diagnoses of dementia and Parkinson’s disease, with a quarterly MDS showing moderately impaired cognition, need for staff supervision with most ADLs, and antipsychotic use during the observation period. The resident’s psychotropic care area assessment identified antipsychotic use and diagnoses of depression and dementia with behavioral disturbance, and the care plan documented Zyprexa for dementia with unspecified severity with agitation. The physician order directed Zyprexa 5 mg at bedtime for dementia with agitation, but the EMR lacked documentation of unsuccessful nonpharmacological approaches for behavioral management and lacked a physician rationale, including risk versus benefits, for continued use. A second resident had a diagnosis of psychotic disorder with delusions and a quarterly MDS showing a BIMS score of 7, indicating severe cognitive impairment, with substantial to maximal staff assistance needed for most ADLs and antipsychotic use during the look-back period. The care plan documented risperidone and instructed staff to administer it as ordered and monitor for side effects and effectiveness, with quarterly consideration of dose reduction when clinically appropriate. The physician order directed risperidone 1 mg twice daily for vascular dementia, but the EMR for the reviewed period lacked evidence that the care plan identified and reported the medication as lacking an acceptable indication and lacked a physician-documented rationale with risks versus benefits and documentation of nonpharmacological interventions attempted and failed. An administrative nurse verified both residents were receiving the antipsychotic medications and stated the facility would contact the physician for appropriate documentation.
Failure to Provide Transfer, Bed Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide Resident 6 and/or the resident’s representatives with a written notification of transfer for facility-initiated transfers and a bed hold policy when the resident was transferred to the hospital. Resident 6’s Discharge MDS documented a planned discharge to an acute hospital with a return anticipated, and the Entry MDS dated 04/23/2026 documented re-entry to the facility from an acute hospital. On 07/29/2026, the facility was unable to provide the requested bed hold, written transfer notification, or LTCO notification related to Resident 6’s hospital transfer. Social Services stated that Administrative Staff A and she had been discussing who would be responsible for sending notifications to the Ombudsman and family, but they had not decided, so the notifications were not provided. Administrative Staff A verified that the bed hold policy had not been provided when Resident 6 was transferred to the hospital and also verified that Ombudsman notification had not been provided, stating the facility had recently obtained a new Ombudsman and she did not give her contact information.
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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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westmoreland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Wamego | 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 | ★★★★★ | 9 | 1 |
| Stoneybrook Retirement Community | 16.8 mi | ★★★★★ | 25 | 0 |
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