Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Westport Place Health Campus during CMS and state inspections, most recent first.
Failure to control resident self-administration and bedside medication storage. A resident with moderate cognitive impairment had antacids left at the bedside and stated a desire to self-administer them, but there was no self-administration assessment or physician order. Another resident with forgetfulness had multiple medication bottles kept in the room despite an assessment stating the resident did not want to self-administer medications and no order for bedside storage or self-administration. Staff confirmed the lack of required orders and assessments.
Respiratory equipment was not cleaned or stored per policy for residents using nebulizers, oxygen, and CPAP. Surveyors observed a resident’s nebulizer mask with dried debris and liquid in the cannister, another resident’s oxygen tubing and cannula lying on the floor or left out of a bag, and a third resident’s CPAP mask sitting on a table instead of being stored in a clean bag. Staff interviews confirmed the expected cleaning and storage practices were not being followed.
Medication administration error rates were 11.11%, above the required threshold of less than 5%. During observation of 27 med passes, surveyors identified three errors. One resident with IBS, constipation, and severe cognitive impairment did not receive ordered polyethylene glycol, and the CRMA said it was withheld because of diarrhea but was not documented. Another resident with DM and constipation had an active Basaglar insulin order, and the report references the insulin priming instructions as part of the observed error review.
Three residents with peripherally inserted central catheters were found with exposed catheter hubs lacking protective caps, despite physician orders requiring capping. Staff interviews revealed inconsistent adherence to procedures for cleaning and capping the catheter hubs after IV medication administration.
Failure to Control Resident Self-Administration and Bedside Medication Storage
Penalty
Summary
The facility failed to allow residents to self-administer medications only when clinically appropriate and in accordance with its own policies and physician orders. Facility policy stated residents could self-administer medications only when specifically authorized by the attending physician and after completion of the self-administration process. The policy for self-administration also required an assessment and physician evaluation before an order for self-medication was obtained. Resident #10 was admitted with a history of GERD and had a BIMS score of 12, indicating moderate cognitive impairment. The resident’s care plan addressed malnutrition risk and directed staff to provide ordered diet, supplements, medications, and adaptive equipment, but it did not include self-administration of medications or leaving medications at the bedside. Observations showed three antacids at the bedside on 02/09/2026, a cup of antacids on the bedside table on 02/10/2026, and a medication cup with three antacids on the over-the-bed table on 02/12/2026. The resident stated they wanted to self-administer medications as needed and keep them at the bedside. The physician order history showed an order for calcium carbonate PRN, but no order to self-administer or keep the medication at the bedside. RN #7 confirmed the resident had no such order and could not locate a self-administration assessment. Resident #69 was admitted with diagnoses including chronic ulcers of both calves with necrosis of the muscle and age-related osteoporosis, and the care plan noted forgetfulness and need for cueing. The resident’s self-administration assessment dated 02/06/2026 indicated the resident did not want to self-administer medications and would not be self-administering them. Despite this, observations showed multiple medication bottles in the room, including collagen peptides, Florastor, zinc, bone support, loratadine, and fluticasone, with some bottles remaining in the windowsill and dresser over several observations and later a bottle of fluticasone on the nightstand. The physician order history showed an order for fluticasone but no orders for the other medications, and no order for bedside storage or self-administration. RN #12 stated the resident did not have an order to keep medications at the bedside or self-administer them, and the DON and ICN stated self-administration required assessment and physician order.
Respiratory Equipment Not Cleaned or Stored Properly
Penalty
Summary
The facility failed to provide respiratory care consistent with its own respiratory equipment policy for residents using nebulizers, oxygen, and CPAP. Surveyors observed used respiratory equipment that was not cleaned, stored, or maintained as required for 3 of 4 residents sampled for respiratory therapy: Residents 30, 48, and 69. The facility policy stated that oxygen cannulas and tubing used PRN should be kept in a plastic bag when not in use, nebulizer equipment should be rinsed, dried, and stored in a plastic bag marked with the resident’s name and date, and CPAP equipment should be stored in a clean plastic bag, although the DNS stated there was no specific policy for CPAP machines. Resident 69 had asthma and an active order for ipratropium-albuterol nebulizer treatments PRN for wheezing and shortness of air. Surveyors observed the resident’s nebulizer machine repeatedly on the nightstand with dried debris in the mask and fluid or liquid in the medication cannister. The equipment was not stored in a bag, and at times the mask and cannister were lying on top of the nightstand or in the top drawer. The resident stated staff laid the mask on top of the machine or in the drawer and that they had not seen staff rinse it out. RN #12 later confirmed the mask was dirty and not stored in a bag, and stated the mask should be wiped out and the cannister rinsed, dried, and stored in the bag. RN #13 stated she had administered a nebulizer treatment and placed the mask in the drawer because there was no bag in the room at that time. Resident 48 had CHF and chronic pulmonary embolism and received oxygen therapy. Surveyors observed oxygen tubing lying on the floor, wadded on top of the concentrator, hanging over the nightstand drawer, and touching the floor from both the concentrator and portable tank. The portable oxygen tank was observed under and behind a chair on its side, with the tubing and nasal cannula touching the floor. RN #12 stated oxygen tubing should be stored in a plastic bag when not in use and that tubing touching the floor should be thrown away and replaced. Resident 30 had OSA and used CPAP. Surveyors observed the CPAP mask on top of a side table rather than stored in a receptacle bag. LPN #10 and the acting DNS stated the CPAP mask should be stored in a respiratory bag when not in use, and the DNS confirmed the mask was not stored in a plastic bag during the observation.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration error rates were found to be 11.11%, exceeding the facility policy and the required threshold of less than 5%. During observation of 27 medication events, surveyors identified three medication errors. The facility policy required use of the five rights and triple checks during medication preparation and administration, and also required documentation when a scheduled medication was withheld, refused, not available, or given at a different time. One error involved a resident with irritable bowel syndrome and constipation, severe cognitive impairment, and an active order for polyethylene glycol 17 grams daily. During medication administration, the CRMA prepared and administered medications but omitted the polyethylene glycol. In interview, the CRMA stated the medication was not given because the resident had diarrhea and acknowledged it should have been documented why it was not given. Another error involved a resident with diabetes mellitus and constipation, moderate cognitive impairment, and an active Basaglar insulin order; the report states the surveyor reviewed the insulin instructions requiring priming before each injection, but the narrative provided cuts off before the specific administration error details are completed.
Failure to Cap Peripherally Inserted Central Catheter Hubs
Penalty
Summary
Surveyors observed that three out of four sampled residents with peripherally inserted central catheters (PICCs) did not have protective caps placed on the end of their catheter hubs, leaving the hubs exposed. These observations were made during routine checks, where the catheter hubs in the residents' upper arms were found uncapped. Review of the facility's policy on catheter insertion and care indicated that a sterile end cap should be applied to the end of primary tubing when disconnected from the catheter, but did not specifically address capping the catheter hub itself. However, physician orders for all three residents explicitly required caps to be placed at the end of the PICC hubs. Interviews with nursing staff and facility leadership revealed inconsistent understanding and implementation of the capping procedure. The acting Infection Preventionist and Assistant DON both acknowledged that caps should be placed on the catheter hubs after disconnection, as per physician orders and standard practice. Nursing staff described their usual practice of cleaning the hub with alcohol and placing a cap after medication administration, but the observed lack of caps on the sampled residents indicated a failure to consistently follow these procedures and physician orders.
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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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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Signature Healthcare At Jefferson Place Rehab & We | 1.2 mi | ★★★★★ | 0 | 0 |
| The Episcopal Church Home | 1.4 mi | ★★★★★ | 13 | 1 |
| Signature Healthcare At Jefferson Manor Rehab & We | 1.5 mi | ★★★★★ | 0 | 0 |
| Lyndon Crossing | 1.5 mi | — | 3 | 2 |
| Sam Swope Care Center | 1.5 mi | ★★★★★ | 5 | 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.