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 Westchester Manor At Providence Place during CMS and state inspections, most recent first.
The facility did not comply with the requirement to keep the interval between the evening meal and breakfast within 14 hours, instead allowing a 14.5-hour gap for all residents across six halls. Staff confirmed the schedule change led to this lapse, and snacks provided outside of meal times were limited and not routinely offered to all residents. The RD and Administrator were unaware of the deficiency until notified by surveyors.
Surveyors identified deficiencies in the Dietary Department, including improper labeling, dating, and sealing of opened food items in storage, failure to discard expired food in the refrigerator, and two dietary staff members working with food without proper facial hair coverage. These lapses were confirmed by the Dining Services Director and Registered Dietitian, who acknowledged the need for adherence to facility policies.
A resident with severe cognitive impairment and a history of falls was unable to access her call light because staff failed to ensure it was within reach, as required by her care plan. The resident was found without a brief and unable to call for assistance until the surveyor intervened. Staff interviews confirmed the oversight, and the DON stated that staff are expected to keep call lights accessible.
Surveyors found that two residents with serious mental health diagnoses had their PASRR Level II status incorrectly coded on their MDS assessments. Despite having official PASRR Level II determinations, the MDS nurse did not recognize the relevant authorization codes as indicating Level II status, resulting in inaccurate reporting.
The facility did not accurately code the MDS assessment for PASRR Level II status and failed to update the care plan for two residents after a change in PASRR determination. For a resident with mental health and dementia diagnoses, the care plan did not reflect the current PASRR status or provide guidance for future care, as staff did not report certain PASRR codes as Level II on the MDS. This resulted in the omission of PASRR findings from the resident's care plan.
The facility failed to protect a resident from abuse when another resident, with a history of physical behaviors, pulled out a section of the resident's hair. Despite immediate staff intervention and 1:1 supervision, the facility did not save the camera footage of the incident. The aggressive resident had become increasingly agitated and combative, with recent infections potentially contributing to her behavioral changes.
The facility failed to maintain the walls and electrical outlet plates in good repair in four of the twenty rooms reviewed on the 500 and 600 halls. Observations revealed gouged drywall, reddish-brown spots on the ceiling, black marks around the perimeter of the room, and a broken red plastic electrical outlet plate. The Maintenance Director acknowledged the issues and stated that repairs were prioritized based on resident safety, but staff shortages had impacted the ability to complete all necessary repairs promptly.
Failure to Maintain Required Meal Interval Between Dinner and Breakfast
Penalty
Summary
The facility failed to ensure that the lapse between the evening meal and breakfast the following day did not exceed 14 hours, as required. A review of the meal service schedule for all six halls revealed that the time between dinner and breakfast was consistently 14 hours and 30 minutes. This schedule was implemented starting January 1, 2025, and affected all residents on the 100, 200, 300, 400, 500, and 600 Halls. Staff interviews confirmed that the meal schedule had recently changed, resulting in the extended lapse, and that prior to the change, the facility had been in compliance with the 14-hour requirement. Further interviews with the Dining Services Director and Chef Manager indicated that while bedtime snacks were available upon resident request, these snacks were limited to packaged items such as crackers, cookies, and chips, and were not routinely provided to all residents. The Registered Dietitian was unaware of the non-compliance with the 14-hour meal interval requirement until it was brought to his attention during the survey. The Administrator also confirmed awareness of the issue after it was identified by surveyors.
Deficiencies in Food Storage, Labeling, and Staff Hygiene in Dietary Department
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's Dietary Department related to food storage, labeling, and staff hygiene practices. During an initial tour, opened food items such as salmon patties, chicken tenders, and hamburger patties were found in the walk-in freezer without proper labeling, dating, or sealing, leaving them exposed to air. Additionally, expired food items, including pork gravy and coleslaw, were found in the reach-in refrigerator, both labeled with expiration dates that had already passed. The Dining Services Director confirmed that facility policy required labeling, dating, and sealing of opened food products, as well as discarding expired items, but these procedures were not followed. Further observations revealed that two dietary staff members, including the Dining Services Director, were working in the kitchen with facial hair that was not properly covered by beard restraints while handling food. On a subsequent observation, the Dining Services Director was seen wearing a beard restraint that did not fully cover his mustache. Both the Director and the facility's Registered Dietitian acknowledged the need for proper facial hair coverage in the kitchen, but staff failed to consistently implement this requirement.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident's call light was within reach, preventing the resident from requesting assistance as needed. The resident, who had a history of repeated falls, type 2 diabetes mellitus, and dementia, was assessed as having severely impaired cognition and required moderate assistance for activities such as toileting, dressing, and transfers. The care plan specifically instructed staff to keep the call bell within reach and provide reminders to use it. During an observation, the resident was found without a brief, which she had removed due to discomfort, and stated she could not locate her call bell. The call bell was observed hanging off the mattress and out of reach, and the resident requested assistance from the surveyor to access it. Staff interviews revealed that the nursing assistant assigned to the resident did not check the location of the call bell before leaving the room and assumed it was within reach. Another nursing assistant and the nurse confirmed that the resident typically used the call bell to request help, but on this occasion, it was not accessible. The Director of Nursing stated that staff are expected to ensure call lights are within residents' reach before exiting rooms. The failure to place the call light within reach directly led to the resident's inability to request timely assistance.
Failure to Accurately Code PASRR Level II Status on MDS Assessments
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments regarding Preadmission Screening and Resident Review (PASRR) Level II status for two residents. For one resident with a diagnosis of major depressive disorder, a PASRR Level II Determination Notification letter indicated a Level II status with no expiration date. However, both the annual and most recent comprehensive MDS assessments incorrectly reported that the resident did not have a PASRR Level II status. The MDS nurse confirmed that the assessments did not reflect the correct PASRR status due to a misunderstanding of the authorization codes, specifically not recognizing codes ending in 'H' or 'B' as indicative of Level II status. Similarly, another resident with diagnoses including bipolar disorder, major depressive disorder, post-traumatic stress disorder, and dementia had a PASRR Level II Determination Notification letter indicating Level II status. The annual MDS assessment for this resident also failed to report the correct PASRR Level II status. The MDS nurse acknowledged that the facility's previous practice was not to report certain PASRR authorization codes as Level II, and was unaware that these codes should be reported as such on the MDS assessment. The administrator was made aware of the issue during the survey.
Failure to Accurately Code PASRR Level II Status and Update Care Plan
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment regarding Preadmission Screening and Resident Review (PASRR) Level II status for two residents. Specifically, for one resident with a history of major depressive disorder, generalized anxiety disorder, and vascular dementia, the PASRR Level II Determination Notification initially indicated a need for specialized services and a 90-day placement approval. However, after a subsequent PASRR determination changed the authorization code from F to H, indicating no restrictions due to a primary diagnosis of dementia, the facility did not update the resident's care plan to reflect the new PASRR status or provide guidance for future care decisions related to PASRR. The care plan did not address the resident's current PASRR status or recommendations from the determination letter. Staff interviews revealed that the facility's practice was not to report residents with PASRR authorization codes of H or B as having a PASRR Level II status on the MDS assessment, which led to the omission of PASRR findings from the care plan. The MDS nurse and Director of Clinical Services confirmed that the resident's care plan was not updated after the PASRR code changed, and the Administrator acknowledged awareness of the issues related to both MDS reporting and care planning for PASRR Level II status.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when another resident pulled out a section of hair from the resident's head. Resident #44, who has diagnoses of unspecified dementia and hallucinations, was observed holding a moderate amount of Resident #13's hair in her hand. This incident occurred in the common area in front of the nurse's station. Resident #13, who has Alzheimer's dementia and orthostatic hypotension, was found with a two-inch reddened area on her back hairline near her neck but voiced no complaints of pain at the time of the incident. Resident #44 had a history of physical behaviors, including hitting, scratching, and throwing objects at staff, which were documented in her care plan. Despite these documented behaviors, Resident #44 was able to propel herself in her wheelchair to Resident #13 and pull out her hair. The facility's staff intervened immediately, separating the two residents and initiating 1:1 supervision for Resident #44. However, the facility did not download and save the camera footage of the incident, which was not available for review during the investigation. Interviews with staff and the psychiatric nurse practitioner revealed that Resident #44 had become increasingly agitated and combative over the past month, exhibiting behaviors such as kicking and spitting on staff. The facility had conducted bloodwork and radiology scans to identify any metabolic reasons for the behavior change but found none. Resident #44 had recently been treated for a urinary tract infection and COVID infection, which the psychiatric nurse practitioner suggested could be contributing to the progression of her dementia and subsequent behavioral changes.
Facility Failed to Maintain Walls and Electrical Outlet Plates in Good Repair
Penalty
Summary
The facility failed to maintain the walls and electrical outlet plates in good repair in four of the twenty rooms reviewed on the 500 and 600 halls. Observations revealed gouged drywall, reddish-brown spots on the ceiling, black marks around the perimeter of the room, and a broken red plastic electrical outlet plate. These deficiencies were noted in rooms 501 A, 509, 601 B, and 603 B during multiple observations over several days. The Maintenance Director acknowledged the issues and stated that repairs were prioritized based on resident safety, but also mentioned that staff shortages had impacted the ability to complete all necessary repairs promptly. During interviews, the Maintenance Director and the Administrator both confirmed that a system was in place for staff to report needed repairs through an online work order system. However, the Maintenance Director admitted that many areas still required attention, and the Administrator indicated that a more consistent process for identifying and reporting repair needs would be implemented. The Administrator also mentioned that training for staff on entering work orders would be part of the new process to ensure timely reporting and addressing of maintenance issues.
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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 High Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meridian Center | 1.8 mi | ★★★★★ | 9 | 2 |
| Magnolia Gardens Center For Nursing And Rehabilita | 4.1 mi | ★★★★★ | 3 | 0 |
| Westwood Health And Rehabilitation | 4.7 mi | ★★★★★ | 18 | 0 |
| Pine Ridge Health And Rehabilitation Center | 5.1 mi | ★★★★★ | 0 | 0 |
| Maryfield Nursing Home | 5.3 mi | ★★★★★ | 1 | 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.