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 Westhaven Nursing Home during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, dependent on staff for transfers and wheelchair use, was allegedly yanked from a wheelchair and dropped forcefully onto a couch by a CNA after being described as combative with care. A family member and an RN both believed the CNA’s actions were abusive. Although the facility’s abuse policy required immediate reporting of suspected abuse to the Administrator or DON, the RN delayed reporting the allegation until the following morning, resulting in a failure to promptly report the suspected abuse.
A resident with dementia, severely impaired cognition, and dependence on staff for transfers and wheelchair use was allegedly abused by a CNA during a night shift. The RN who witnessed or became aware of the abusive behavior did not know the facility’s abuse procedure, did not remove the CNA from duty, and delayed reporting the allegation to the DON until the following morning, allowing the CNA to complete the shift. This response conflicted with the facility’s abuse policy, which required suspension of an employee during an abuse investigation.
A resident admitted with malnutrition, GI hemorrhage, and dysphagia, and receiving tube feeding, experienced an 8.66% weight loss over about one month, as shown by weight records. Despite this, the admission MDS documented that the resident had not lost 5% or more body weight in the prior month. An LPN reported the resident was placed on five daily bolus feedings of Jevity 1.5 for a few days, and the MDS coordinator later acknowledged that the admission assessment should have reflected a weight loss greater than 5% in one month.
A resident with malnutrition, GI hemorrhage, dysphagia, and a feeding tube experienced significant weight loss over about one month, but the care plan was not updated to reflect this change or add specific interventions. The existing care plan only noted the need for tube feeding and periodic RD evaluation, despite physician orders for multiple daily bolus feedings of Jevity 1.5. During interviews, an LPN reported the resident received five bolus feedings daily for a few days, and the MDS coordinator acknowledged that the care plan should have documented the greater than 5% monthly weight loss and included measures to prevent further loss.
Surveyors found that daily nurse staffing information was consistently posted on a bulletin board down a hallway rather than in a prominent, easily visible area such as the main lobby or front entrance. The DON and administrator acknowledged that the posting location was not readily visible to all residents and visitors unless they already knew where to look, despite dozens of residents residing in the facility at the time.
Surveyors identified that the facility failed to remove expired medications and medical supplies from a medication supply room and a medication cart, despite a policy requiring constant review and rotation to prevent expiration. In the supply room, multiple expired wound care dressings and an opened Tubersol vial without an open date were found, and another Tubersol vial remained beyond the 30-day use period. On one hall’s medication cart, an expired box of Naloxone nasal spray was present. Nursing staff and the DON acknowledged that these expired items should have been removed and that opened vials should have been properly dated and discarded within the required timeframe.
A CNA failed to remove soiled gloves or perform hand hygiene after providing perineal care to a resident, then proceeded to handle clean items such as blankets and a bed remote, contrary to facility policy requiring glove removal and handwashing before touching clean areas.
The facility did not complete discharge summaries for three residents who were discharged. A review of their records showed the absence of these summaries, and the DON confirmed the oversight.
A facility did not ensure a pharmacy's medication regimen review recommendation was sent to a physician for a resident with diabetic neuropathy. The resident was prescribed Gabapentin 600 mg TID, but a review suggested a dose reduction due to renal function. No documentation showed the recommendation was acted upon, and the DON could not find the physician's response.
The facility failed to implement a 14-day stop date for as-needed lorazepam for a resident with anxiety and did not act on a Medication Regimen Review request for dose reduction of psychotropic medications for another resident with anxiety and depression. The oversight in medication management was acknowledged by staff, and the Director of Nursing could not locate a physician's response to the review request.
The facility failed to remove expired medications and supplies from the medication storage room, as observed during a tour with the DON. Expired items included Ipratropium Bromide and Albuterol Sulfate, collection and transport swab packets, Milk of Magnesia, and Narcan nasal spray. Additionally, a bottle of Lantus insulin was found opened and undated. The DON acknowledged the oversight.
A resident with Alzheimer's and dementia developed a new pressure ulcer, but the facility failed to notify the physician as required. The wound was documented and treated with calazime, but there was no record of physician notification. The DON confirmed the oversight during a wound care observation.
A facility failed to ensure safe medication administration when a resident was observed with two medication cups left on their bedside table while eating breakfast. Despite the policy requiring staff to stay with residents until medications are swallowed, an RN left the medications with the resident, who intended to take them later, violating the facility's guidelines.
A facility failed to implement Enhanced Barrier Precautions (EBP) during incontinent and indwelling catheter care for a resident. Despite a policy requiring gowns and gloves for high-contact activities, staff did not wear gowns while providing care. The CNA and CMA involved were unsure if EBP should be used during such care, indicating a lack of adherence to infection control protocols.
Failure to Immediately Report Alleged Abuse of a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure an allegation of abuse was immediately reported as required by its policy. The facility’s undated “Patient Abuse” policy stated it was strictly prohibited for any employee to fail to immediately report an incident of patient abuse to the Administrator or DON. Resident #1, admitted on 01/25/26, had severely impaired cognition with a BIMS score of 03, diagnoses including dementia, and was dependent on staff for transfers and required substantial/maximal assistance for wheelchair use. An incident report dated 02/12/26 documented an allegation of abuse that occurred on 02/11/26 at approximately 11:00 p.m., when RN #1 observed CNA #1 behave in an abusive manner toward Resident #1. Family member #1 reported they had been called to the facility around 10:30 p.m. to 11:00 p.m. because Resident #1 was being combative with care and requested the resident be transferred to a couch where they had been sleeping recently. Family member #1 stated CNA #1 yanked the resident up from the wheelchair and dropped them down on the couch with force, and they felt the CNA’s actions were abusive. RN #1 stated they had asked CNA #1 to transfer Resident #1 from the wheelchair to the couch in the common area, and that CNA #1 was mad and aggressively transferred the resident. RN #1 stated they and family member #1 both felt the CNA’s actions were abusive, but RN #1 did not report the incident to the DON until 6:00 a.m. the next morning, rather than immediately. The administrator stated they reported the abuse allegation and started an investigation as soon as they were made aware of the incident by RN #1, and the DON stated the incident should have been reported to them or the administrator immediately by RN #1.
Failure to Immediately Remove Alleged Perpetrator After Abuse Allegation
Penalty
Summary
The facility failed to immediately protect a resident from potential further abuse after an allegation against a CNA. An admission assessment for Resident #1, who had dementia, severely impaired cognition with a BIMS score of 03, and was dependent on staff for transfers and wheelchair use, documented the resident’s condition. An incident report showed that on 02/11/26 at approximately 11:00 p.m., an allegation of abuse by CNA #1 toward Resident #1 occurred, but RN #1 did not report the allegation to the DON until 6:00 a.m. on 02/12/26. During this time, CNA #1 was not removed from duty and was allowed to continue working, as confirmed by a timesheet showing CNA #1 clocked out at 6:15 a.m. on 02/12/26. The facility’s undated Patient Abuse policy stated that to protect the resident during an abuse investigation, the employee would be suspended during the investigation process. RN #1 stated they did not send CNA #1 home after witnessing the abusive behavior and did not know the facility’s abuse procedure, waiting until the next morning to report the allegation. The DON stated CNA #1 should have been sent home immediately and should not have been allowed to finish the shift. This sequence of events demonstrates that the facility did not follow its own abuse policy and failed to immediately remove the alleged perpetrator from resident care after an abuse allegation involving Resident #1.
Inaccurate MDS Assessment of Significant Weight Loss
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for one resident when the admission MDS did not reflect a significant weight loss that had occurred prior to and at the time of admission. Record review showed the resident, admitted with malnutrition, gastrointestinal hemorrhage, and dysphagia and requiring nutrition via feeding tube, weighed 213.6 pounds on 12/24/25 and 198.4 pounds on 01/19/26, with an admission assessment weight of 195 pounds on 01/23/26. This represented an 8.66% weight loss between 12/24/25 and 01/23/26. However, the admission MDS documented that the resident had not experienced a weight loss of 5% or more in the last month. During interview, an LPN reported the resident had been placed on five daily bolus feedings of Jevity 1.5 for a few days, and the MDS coordinator, after reviewing the weight summary, acknowledged that the admission assessment should have indicated a weight loss of over 5% in one month.
Failure to Update Care Plan for Significant Weight Loss in Tube-Fed Resident
Penalty
Summary
The facility failed to update and implement a comprehensive care plan to address significant weight loss for one resident who received nutrition via a feeding tube. Record review showed the resident weighed 213.6 pounds on 12/24/25 and 198.4 pounds on 01/19/26, an 8.66% loss between 12/24/25 and 01/23/26, yet the existing care plan dated 12/29/25 only reflected that the resident required tube feeding and included an intervention for the registered dietitian to evaluate quarterly and as needed, with no update documenting the significant weight loss or additional interventions. A physician’s order dated 01/17/26 directed bolus feedings of Jevity 1.5 five times daily, and the admission MDS documented diagnoses including malnutrition, gastrointestinal hemorrhage, and dysphagia, with tube feeding required and no prior 5% or greater weight loss in the last month. During interview, an LPN stated the resident was placed on five bolus feedings daily for a few days, and the MDS coordinator, after reviewing the weight summary, acknowledged the care plan should have reflected the resident’s greater than 5% monthly weight loss and included interventions to prevent further weight loss. This deficiency involved the facility’s inaction in revising the care plan despite documented significant weight loss and existing clinical information indicating the resident’s nutritional risk, as well as reliance on assessments for weight information without ensuring that the care plan was updated to address the change in condition.
Failure to Post Daily Nurse Staffing Information in a Prominent Location
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted in a prominent location readily accessible to residents, staff, and visitors. On two separate observations, the daily nurse staffing information sheet was found posted on a bulletin board partway down hall 4, rather than in a clearly visible area such as the main lobby or front entrance. During these observations, the posting was not clearly visible to all visitors and residents. The DON acknowledged that the daily nurse staffing information sheet was not posted in the main lobby area and would not be visible to all residents and visitors who did not know where it was located, stating it had always been kept down hall 4 on the bulletin board. The administrator similarly confirmed that the daily nurse staffing information sheet was not posted at the front entrance and was not visible to all residents and visitors who did not know where to look. At the time of the survey, the DON identified that 62 residents resided in the facility. These observations and interviews demonstrate that the facility did not comply with the requirement to post nurse staffing information in a prominent, readily accessible place for all residents, staff, and visitors.
Expired Medications and Supplies Not Removed From Storage and Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure expired medications and medical supplies were removed from storage areas and a medication cart, as required by professional standards and the facility’s own policy on expired medications. In the medication supply room, multiple wound care products were observed to be past their expiration dates, including several packages of IoFlex iodophor foam dressings, Maxorb II alginate wound dressings, Sorbalgon calcium alginate dressings, Tegaderm film dressings, Zetuvit Plus silicone border dressings, and an Optifoam heel foam non-adhesive dressing. Additionally, one Tubersol vial was opened and dated, and another Tubersol vial was opened with no date indicating when it was opened, contrary to expectations that such vials be dated and discarded after 30 days. On a medication cart for one hall, surveyors observed a box of Naloxone hydrochloride nasal spray with an expiration date indicating it should already have been removed. Staff interviews confirmed that the expired medications and supplies should have been removed from the medication/storage room and that the Tubersol vial should have been dated and discarded after 30 days. Another staff member acknowledged that the Naloxone should have already been removed from the cart. The DON also stated that the expired medications and supplies should have been removed, confirming that the facility did not follow its policy to rotate and review medications on a constant basis to prevent expired items from remaining available for use.
Failure to Follow Infection Control Practices During Incontinent Care
Penalty
Summary
During an observation of incontinent care provided to one resident, two CNAs entered the resident's room to perform perineal care. CNA #1 was observed removing blankets and a pillow, assisting the resident to their side, and cleaning the perineal area with disposable wipes, using each wipe only once before discarding. After completing the cleaning, CNA #1 replaced the pillow, pulled up the blankets, and used the bed remote, all while still wearing the same gloves used during the perineal care. CNA #1 did not remove the soiled gloves or sanitize their hands before touching clean items and areas, contrary to the facility's perineal care policy, which requires glove removal and hand hygiene before handling clean items. CNA #1 later acknowledged not following the glove removal policy prior to touching clean areas.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to complete discharge summaries for three residents who were discharged from the facility. Resident #60 was discharged on August 22, 2024, Resident #67 on May 29, 2024, and Resident #69 on May 31, 2024. Upon review of their records, it was found that none of these residents had a discharge summary documenting their stay. The Director of Nursing (DON) confirmed on August 28, 2024, that the discharge summaries were not completed for these residents.
Failure to Act on Pharmacy Recommendation for Medication Adjustment
Penalty
Summary
The facility failed to ensure that a Medication Regimen Review (MRR) pharmacy request was sent to the physician for action regarding a resident's medication. The resident, who had a diagnosis of diabetic neuropathy, was prescribed Gabapentin 600 mg three times daily. A MRR conducted on 06/11/24 recommended a dose reduction based on the resident's renal function, suggesting a maximum dosage of 700 mg twice daily. However, there was no documentation in the resident's clinical record indicating that the recommendation had been acted upon. The Director of Nursing (DON) was unable to locate the physician's response to the MRR pharmacy recommendation letter.
Failure to Implement Psychotropic Medication Protocols
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications. For one resident with a diagnosis of anxiety, the facility did not implement a 14-day stop date for as-needed lorazepam orders. The orders were documented with a re-evaluation date instead of a set stop date, leading to the continuation of the medication without proper review. This oversight was acknowledged by a corporate nurse who stated that the orders should have been entered with a set stop date. Another resident, diagnosed with anxiety and depression, was prescribed lorazepam and bupropion. A Medication Regimen Review (MRR) requested a gradual dose reduction of these medications, as per state and federal guidelines. However, the facility failed to act on this request, as the Director of Nursing (DON) could not locate a physician's response to the MRR. This inaction indicates a lapse in following up on medication reviews and ensuring appropriate medication management for the resident.
Expired Medications and Supplies Found in Medication Storage Room
Penalty
Summary
The facility failed to ensure the removal of expired medications and supplies from the medication storage room, as observed during a tour with the Director of Nursing (DON). Several expired items were found, including boxes of Ipratropium Bromide and Albuterol Sulfate with use-by dates ranging from April to November 2024, collection and transport swab packets expired since February 2024, and multiple bottles of Milk of Magnesia with use-by dates from March to August 2024. Additionally, a bottle of Lantus insulin was found opened and undated, and Narcan nasal spray boxes with expiration dates as far back as November 2013 were present. The DON acknowledged that the insulin should have been dated when opened and that expired medications and supplies should have been removed before their use-by dates.
Failure to Notify Physician of New Pressure Ulcer
Penalty
Summary
The facility failed to notify the physician of a new pressure ulcer for a resident diagnosed with Alzheimer's disease and dementia. The resident developed an open area measuring 0.5 cm by 0.5 cm with red-tinged drainage, as documented in a progress note dated 07/27/24. The wound was cleaned, patted dry, and calazime barrier cream was applied, but there was no documentation indicating that the physician was notified of the new wound. On 08/27/24, during an observation of wound care, the Director of Nursing (DON) confirmed that the physician should have been notified on the day the wound was discovered, but there was no evidence of such notification.
Failure to Ensure Safe Medication Administration
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for one of the six sampled residents reviewed for medications. During an observation, a resident was seen sitting in their room eating breakfast with two medication cups on their bedside table. One cup contained two white tablets, and the other contained 12-15 tablets/capsules. When questioned, RN #1 stated that the policy for administering medications involved checking the physician's orders, punching the medications out, initialing the MAR, and staying with the resident until they swallowed the medications. However, RN #1 left the medication cups on the resident's bedside table after the resident expressed a desire to take them after breakfast, contrary to the facility's policy and inservice education guidelines that medications should not be left in residents' rooms.
Failure to Implement Enhanced Barrier Precautions During Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during incontinent care and indwelling catheter care for one of the five sampled residents reviewed for infection control. The Director of Nursing identified nine residents with Foley catheters and 23 with EBP in place. An undated policy on EBP indicated that staff must wear gowns and gloves during high-contact resident care activities, such as changing briefs and urinary catheter care. An EBP sign was posted on the outside of the resident's door, instructing staff to wear gloves and a gown during transfers and urinary catheter activity. On the morning of the observation, a resident was seen sitting in a wheelchair with a lift sling under them, and a urinary drain bag was hooked under the wheelchair. Two staff members, a CNA and a CMA, cleaned their hands and donned gloves before transferring the resident to their bed using a lift. The CMA provided peri care and indwelling catheter care, while the CNA provided incontinent care. However, neither staff member wore gowns during these procedures. When asked about the EBP policy, the CMA mentioned that EBP should be used for residents with specific conditions but was unsure if it should be implemented during incontinent and urinary catheter care.
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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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Nursing homes near Stillwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stillwater Creek Skilled Nursing And Therapy | 1.3 mi | ★★★★★ | 0 | 0 |
| Perry Green Valley Nursing Center, Llc | 16.8 mi | ★★★★★ | 0 | 0 |
| Linwood Village Nursing & Retirement Apts | 20.9 mi | ★★★★★ | 0 | 0 |
| Southern Oaks Care Center | 22.1 mi | ★★★★★ | 9 | 0 |
| Golden Age Nursing Home Of Guthrie, Llc | 24.5 mi | ★★★★★ | 0 | 0 |
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