Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Stonebridge Westphalia during CMS and state inspections, most recent first.
Incomplete Legionella Water Management Program: Facility staff failed to develop and implement complete water management policies and procedures to prevent Legionella growth. The program lacked facility-specific policies, did not identify the water management team, and did not include control measures or corrective actions for sinks or shower heads. Staff also did not document flushing of low-use water areas, and the ice machine had an overdue filter while the ENV Svcs Dir and administrator acknowledged gaps in oversight and monitoring.
Incomplete Care Plans for Self-Administered Bedside Medications: Facility staff did not develop person-centered care plans with measurable goals and timeframes for three cognitively intact residents who self-administered meds and kept them at bedside. Care plans for residents with respiratory failure, lung disease, and non-Alzheimer dementia lacked direction for self-administration and bedside storage, while observations showed nasal sprays, inhalers, and medication cups left on overbed tables or nightstands with roommates nearby.
Failure to provide scheduled bathing and hygiene assistance for three residents. Residents with cognitive impairment and ADL dependence had missing shower documentation across multiple scheduled baths, and one resident had an unsigned refused shower sheet. Surveyors observed foul odor, greasy hair, and long facial hair, and a family member reported the resident often smelled and did not appear to be showered twice weekly. Staff interviews confirmed showers were scheduled by room number, refusals were to be documented, and the DON was aware of shower completion issues.
Medication was left at the bedside of three residents despite facility policy requiring secure storage unless self-administration is authorized. Staff observed nasal spray and inhalers on overbed tables for two cognitively intact residents, with roommates nearby, and medication cups with capsules and tablets on another resident’s nightstand while the resident was out of sight in the bathroom. Interviews showed staff were not aware of residents self-administering medications or keeping them at bedside, and the administrator said bedside storage should not occur unless assessed and ordered.
Failure to provide bed hold notice during hospital transfers: Two residents were transferred to the hospital and later readmitted, but their records lacked documentation that written bed hold information was given to the resident or responsible party. Facility policy required the notice before transfer if possible, or within the required timeframe for emergency transfers. Interviews showed mixed understanding among staff about who was responsible for completing and sending the notice, and the administrator stated the EMR should trigger the bed hold during discharge.
Facility staff did not complete weekly skin assessments for three residents, as required by policy. A resident with multiple unhealed pressure ulcers did not receive assessments for three months. Another resident had only one assessment in the same period, and a third resident had no weekly assessments after admission. Interviews revealed staff were unaware of their responsibilities, and the DON was uncertain about assessment frequency.
Staff failed to ensure medications were stored safely and effectively, with issues including improperly labeled medications, undated opened bottles, expired medications, and unsecured controlled substances. Interviews revealed non-compliance with the facility's medication storage policies.
Facility staff failed to perform appropriate hand hygiene and glove changes during incontinence and catheter care for residents, and did not properly sanitize a multi-use glucometer between uses. CNAs and an LPN did not follow proper procedures, leading to potential infection risks. The DON and administrator confirmed the expectations for hand hygiene, glove changes, and disinfection.
The facility staff failed to provide an ongoing program of activities on weekends, leaving residents without adequate engagement options. The activity calendar showed limited activities, primarily Rosary and Catholic Church services, which did not cater to all residents' preferences. Interviews with residents and staff confirmed the lack of organized activities, resulting in residents feeling unengaged and spending weekends in their rooms.
Facility staff failed to ensure the arbitration agreement was explained correctly and did not provide an option to decline. The SSD admitted to not reading the agreement to residents or families and was unaware of its implications. The administrator confirmed it was the SSD's responsibility to explain the form but was unaware of the issue.
Facility staff failed to ensure call lights were within reach for three residents, leading to potential safety risks. Observations showed residents with cognitive impairments and dependencies for ADLs without accessible call lights, despite facility policy and staff acknowledgment of the importance of call light accessibility.
Facility staff failed to post the required DHSS hotline number and SSA information in an accessible manner. Interviews with residents and staff revealed a lack of awareness regarding the location of this information. The DON and administrator acknowledged the oversight but were unaware of the deficiency.
Incomplete Legionella Water Management Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens and reduce the risk of Legionella. Review of the facility’s Legionella Water management program in April 2025 showed the program did not contain facility-specific policies related to water management for prevention of Legionella and did not identify members of the water management team. Staff identified shower heads, sinks, and ice machines as potential risk areas, but the program only included replacement of the ice machine filter on a regular schedule without specifying a frequency. The program also did not contain control measures related to sinks or shower heads and did not include actions to be taken when specified control limits were not met. During the Life Safety Code tour, the ice machine contained a filter dated 03/27/24. The Environmental Services Director stated staff flushed low-use water areas but did not document the flushes, was not familiar with any risk areas other than low-use areas, and said he/she was responsible for changing the ice machine filter every six months but had missed the change. The administrator stated he/she was responsible for the Legionella program, had started reviewing and updating it in April 2025 but had not completed the review, and said the water management team did not have regular meetings.
Incomplete Care Plans for Self-Administered Bedside Medications
Penalty
Summary
Facility staff failed to develop comprehensive person-centered care plans with measurable objectives and timeframes for three residents who self-administered medications and kept medications at the bedside. The facility policy required care plans to describe services to meet each resident’s physical, psychosocial, and functional needs and reflect the resident’s expressed wishes regarding care and treatment goals. Review of the records showed that Resident #21 was cognitively intact with a diagnosis of respiratory failure, Resident #29 was cognitively intact with a diagnosis of lung disease, and Resident #48 was cognitively intact with a diagnosis of non-Alzheimer dementia. For Resident #21, the care plan dated 06/08/25 did not include direction or guidance for self-administration of medication or keeping medication at bedside, yet observation showed a bottle of nasal spray and an albuterol inhaler on the overbed table, with the roommate sitting in reach of the medication, and the resident stated the medication was taken as needed and always kept in the room. For Resident #29, the care plan dated 06/20/25 also lacked direction or guidance for self-administration or bedside medication storage, while observation showed nasal spray and a Combivent inhaler on the overbed table with the roommate nearby, and the resident stated the medications were kept in reach and used as needed. For Resident #48, the care plan dated 07/23/25 did not address self-administration or keeping medication at bedside, while observation showed three medication cups with an unknown number of capsules and tablets on the nightstand with the roommate in proximity and the resident out of sight in the bathroom; the resident stated nurses leave the medication because he/she can take it independently.
Failure to Provide Scheduled Bathing and Hygiene Assistance
Penalty
Summary
Facility staff failed to ensure residents who were unable to complete activities of daily living received the necessary assistance to maintain good grooming and personal hygiene. The facility’s Bath, Shower/Tub policy required documentation of the date and time of the bath, the staff member assisting, assessment data, refusals and interventions, and the signature and title of the person recording the data. The facility census was 54, and the deficiency involved three sampled residents who required assistance with bathing as scheduled. Resident #9’s MDS showed cognitive impairment, dementia, no behaviors or rejection of care, and a need for substantial to maximum assistance with showers/tub baths and partial to moderate assistance with transfers. The resident’s care plan directed staff to assist with all ADLs, and the shower schedule called for showers every Monday and Thursday. The shower record from 04/23/25 through 07/23/25 did not document showers on multiple scheduled dates, and the medical record contained one unsigned, undated shower sheet marked refused. The resident was observed on 07/22/25 and 07/23/25 with a foul odor. Resident #10’s quarterly MDS showed severe cognitive impairment, verbal and physical behaviors, no rejection of care, impaired range of motion in all extremities, and dependence on staff for shower/tub baths and transfers. The care plan directed staff to assist with all ADLs, and the shower schedule also called for showers every Monday and Thursday. The shower record lacked documentation for multiple scheduled showers during the review period. The resident was observed on 07/22/25 with greasy hair and long facial hair and again on 07/23/25 with greasy hair and long facial hair. Resident #15’s quarterly MDS showed cognitive impairment, no behaviors or rejection of care, and a need for supervision to touch assist with shower/tub baths and transfers. The care plan directed staff to assist the resident, but the shower record lacked documentation for multiple scheduled showers, and the resident was observed on 07/22/25 in bed with a foul odor. The resident’s family stated the resident is incontinent, often has a smell, and did not appear to be getting showered as often as twice a week.
Medication Left at Bedside Without Authorized Self-Administration
Penalty
Summary
Facility staff failed to ensure the resident environment remained free from accident hazards when medication was left at the bedside of three residents. The report states that the facility’s policies required medications to be stored in a safe and secure place and, if self-administration was not authorized, medications found at the bedside were to be given to the charge nurse for return to the pharmacy or family. However, staff observed a bottle of nasal spray and an albuterol inhaler on the overbed table for one cognitively intact resident with respiratory failure, with the roommate sitting in reach of the medication. The same resident was again observed with the nasal spray and inhaler on the overbed table two days later, with the roommate nearby. A second cognitively intact resident with lung disease was observed with a bottle of nasal spray and a Combivent inhaler on the overbed table, and the roommate was in proximity to the table during both observations. A third cognitively intact resident with non-Alzheimer dementia was observed with three medication cups containing an unknown number of capsules and tablets stacked on the nightstand while the roommate was nearby and the resident was in the bathroom, out of sight of the medications. During interviews, the resident said staff leave the medications so he/she can take them independently. Staff interviewed stated they were not aware of residents who self-administer medications or keep medications at the bedside, and the administrator said residents should not keep medication at bedside unless assessed by staff and ordered by the physician.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
Facility staff failed to provide written bed hold information to the resident and/or the resident’s representative when two residents were transferred to the hospital. Review of the facility’s policies showed that written bed hold notice should be provided prior to transfer if possible, or within the required timeframe for emergency transfers. However, the medical records for two residents showed they were discharged to the hospital and later readmitted, and neither record contained documentation that a bed hold notice was issued to the resident or the responsible party. During interviews, the SSD stated nurses were responsible for completing and sending bed hold notices with residents on discharge, and that in emergency transfers nurses were responsible for calling the resident contact to discuss the bed hold by phone. An LPN stated he/she had not sent a bed hold notice and did not know who was responsible for completing it, while another LPN said bed holds are sent with the resident on discharge and, if the transfer is emergent, the nurse should contact the responsible party and inform them of the bed hold. The administrator stated nurses are responsible for sending bed holds with residents going to the hospital, and that if it is an emergency transfer the SSD can send it the next day, but the EMR should trigger a bed hold during discharge and he/she did not know why bed holds were missing for the two residents.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
Facility staff failed to adhere to professional standards by not completing weekly skin assessments for three residents, as required by the facility's Pressure Injury Prevention and Management Policy. The policy mandates that licensed nurses conduct full body skin assessments upon admission, readmission, and weekly thereafter, with findings documented in the medical record. However, for Resident #1, who was at risk for pressure ulcers and had multiple unhealed pressure ulcers, staff did not complete the required skin assessments from admission through a three-month period. Similarly, Resident #2, who was also at risk for pressure ulcers, had only one skin assessment completed during the same timeframe, and no assessment was done upon readmission. Resident #3, with multiple pressure ulcers, had an initial assessment upon admission but no subsequent weekly assessments were conducted. Interviews with facility staff, including LPNs and the DON, revealed a lack of awareness and responsibility regarding the completion of skin assessments. LPN D, who works part-time, indicated that skin assessments are prompted by the Treatment Administration Record (TAR) and was unaware of any missing assessments. The DON, new to the position, was uncertain about the frequency of assessments and acknowledged it was their responsibility to ensure completion. The administrator confirmed that skin assessments should be conducted upon admission, readmission, and weekly, assigning responsibility to the DON, Assistant DON, and wound care nurse, but was unaware of the reasons for the lapses in assessments.
Medication Storage Deficiencies
Penalty
Summary
Staff failed to ensure medications were stored in a safe and effective manner, as observed on two medication carts. Medications were not properly labeled and were not contained in their original packaging until the time of administration. Specifically, an envelope with two pills was found on the 200 hall medication cart, and three loose pills were found on the 100 hall medication cart. Additionally, multiple opened bottles of medications on the 100 hall medication cart were undated, including Milk of Magnesia, polyethylene glycol 3350 powder, megestrol acetate oral suspension, guaifenesin oral solution, and Carbamazepine suspension. The facility's policy requires medications to be stored in their original containers and dated when opened, which was not followed in these instances. Further deficiencies were noted in the medication room, where expired medications were found, including bottles of aspirin, magnesium, cranberry, and vitamin A. Additionally, two vials of Lorazepam, a controlled medication, were found in an unlocked box in the medication room refrigerator, contrary to the requirement that controlled medications be stored in a separately locked, permanently affixed compartment. Interviews with staff, including the administrator, CMTs, and the DON, revealed a lack of adherence to the facility's medication storage policies and procedures, contributing to the observed deficiencies.
Infection Control Deficiencies
Penalty
Summary
Facility staff failed to perform appropriate hand hygiene and glove changes during incontinence care for two residents. One CNA did not change gloves between clean and dirty tasks and did not perform hand hygiene after removing soiled gloves. Another CNA did not perform hand hygiene before applying gloves and used the same soiled gloves to handle clean items and equipment. Both CNAs acknowledged their mistakes during interviews, and the DON confirmed the expectations for hand hygiene and glove changes to prevent the spread of infection. Facility staff also failed to perform appropriate hand hygiene and glove changes during catheter care for one resident. The CNA did not perform hand hygiene before applying gloves and used the same wipe multiple times on different areas, including the catheter tubing. The CNA admitted to being in a hurry and not following proper procedures. The DON and the administrator emphasized the importance of hand hygiene, glove changes, and using a clean wipe for each swipe to prevent introducing bacteria into the catheter. Additionally, facility staff failed to appropriately sanitize a multi-use glucometer between use for two residents. An LPN used alcohol wipes instead of the approved disinfectant wipes and did not perform hand hygiene after removing gloves. The Infection Preventionist and the DON clarified that alcohol is not appropriate for disinfecting glucometers and that the correct wipes should be used. The administrator expects staff to use two glucometers and follow proper disinfection procedures to prevent cross-contamination.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility staff failed to provide an ongoing program of activities designed to meet the interests of three residents on the weekends. The facility's policy, titled Life Enrichment Program, mandates that activities should enhance residents' well-being, promote physical and cognitive activities, and reflect residents' interests and choices. However, the activity calendar for May 2024 showed limited activities on weekends, primarily consisting of Rosary and Catholic Church services, which did not cater to all residents' preferences and needs. Resident #5, who is cognitively intact and values group activities, expressed that weekends are uneventful and drag on without activities. Resident #13, who is independent in decision-making and enjoys reading, favorite activities, and religious services, also noted the lack of weekend activities and expressed a desire for more engagement. Similarly, Resident #41, who values group activities and reading, reported spending weekends in their room due to the absence of suitable activities, as they do not participate in Catholic services. Interviews with facility staff, including a Nurse Aide, Certified Medication Tech, Registered Nurse, Activity Director, Director of Nursing, and the Administrator, confirmed the lack of organized activities on weekends. The Activity Director mentioned that residents receive packets with coloring sheets and word searches on Fridays, but these do not adequately address the diverse interests of all residents. The Director of Nursing and Administrator acknowledged the limited weekend activities, primarily focused on Rosary and family visits, leaving non-Catholic residents without appropriate engagement options.
Failure to Properly Explain Arbitration Agreement
Penalty
Summary
The facility staff failed to ensure that the arbitration agreement was explained in a form and manner that correctly described the arbitration process and the option to decline the agreement. The facility's policies did not include a policy for Arbitration Agreements, and the Admission Packet's one-page Arbitration Agreement lacked a place to decline arbitration. During an interview, the Social Services Director (SSD) admitted to not typically reading the arbitration agreement to residents or their families and was unaware that signing the agreement meant they could not take matters to court. The administrator confirmed that it was the SSD's responsibility to explain the form and answer any questions during the admission process but was unaware that the information was not being explained correctly.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
Facility staff failed to ensure call lights were within reach for three residents out of 13 sampled residents. Resident #6, who was cognitively moderately impaired and dependent for activities of daily living (ADLs) and transfers, was observed multiple times with the call light attached to the lower bedrail and not within reach while in his/her wheelchair. Similarly, Resident #42, who was cognitively impaired and dependent for ADLs and transfers, was observed several times in a broda chair with the call light not within reach, and at one point, the resident was heard yelling for help. Resident #37, who had clear comprehension but was severely impaired in making decisions and required substantial assistance with ADLs and transfers, was observed multiple times with the call light on the floor beside the bed and not within reach while in his/her wheelchair. Interviews with facility staff, including a Certified Nurse Aide (CNA), a Registered Nurse (RN), the Director of Nursing (DON), and the administrator, confirmed that call lights should always be within reach of residents. The staff acknowledged that if call lights are not within reach, residents may attempt to get up and fall, potentially leading to danger. The facility's policy on call light accessibility and response, dated 9/21, mandates that staff ensure call lights are within reach and accessible to residents, but this was not adhered to in the observed cases.
Failure to Post Required Hotline Information
Penalty
Summary
Facility staff failed to post the required telephone number to the Department of Health and Senior Services (DHSS) hotline for reporting allegations of abuse and neglect, as well as a list of names, addresses, and phone numbers of the State Survey Agency (SSA). This deficiency was identified through observation, interview, and record review. The facility's policy, dated October 2017, mandates that required postings be accessible to all staff and residents. However, during a survey conducted from 05/06/24 to 05/09/24, it was observed that the necessary information was not posted in a form and manner accessible to residents or visitors. The facility census was 50 at the time of the survey. Interviews with residents and staff revealed a lack of awareness regarding the location of the hotline number. One resident stated they did not know where the hotline number was posted and had not been informed of its location. Another resident confirmed that the hotline number was not posted anywhere but should be. A Certified Medication Technician (CMT) and the Social Service Designee (SSD) both expressed uncertainty about the posting of the hotline number, with the SSD unable to locate it in the dining room as initially thought. The Director of Nursing (DON) and the administrator acknowledged that the required information should be posted visibly for everyone to see but were unaware that it was not. The administrator indicated that the SSD was responsible for ensuring the information was posted but could not explain why it was not done.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 31 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westphalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Adams Street | 13 mi | ★★★★★ | 6 | 0 |
| Capitol River Wellness & Rehabilitation | 13.5 mi | ★★★★★ | 0 | 0 |
| Stonebridge Villa Marie | 13.7 mi | ★★★★★ | 0 | 0 |
| Jefferson City Manor Care Center | 14 mi | ★★★★★ | 8 | 0 |
| Heisinger Bluffs Rehab And Healthcare Center | 14.1 mi | ★★★★★ | 0 | 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.