Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Westwood Center during CMS and state inspections, most recent first.
A resident with dementia, diabetes, and peripheral neuropathy sustained severe foot injuries after repeatedly propping feet on heaters and picking at skin, despite known risks and documented resistance to care. Staff failed to provide adequate supervision and did not consistently monitor or intervene to prevent access to hazards or address self-injurious behaviors, resulting in wounds that required hospitalization and burn center treatment.
Two residents experienced deficiencies in care due to staff failing to administer medication as ordered and not ensuring a pressure redistribution mattress was functioning. One resident did not receive carvedilol as prescribed, and another had an unplugged air mattress, contrary to medical orders. These issues were discussed with facility administration, but no further information was provided before the survey exit.
The facility failed to provide adequate supervision for two residents, resulting in harm and elopement. One resident, with a history of cognitive impairments, was left unsupervised during meals despite requiring assistance, leading to their death. Another resident, with severe cognitive impairment, eloped from the facility due to an ineffective wander guard device and was found outside by dumpsters. These incidents highlight significant lapses in supervision and safety measures.
The facility staff failed to properly dispose of and contain garbage and waste in the designated disposal area. Surveyors observed scattered debris, including gloves, Styrofoam cups, a trash bag with unknown contents, and pieces of wood around two dumpsters on the facility's campus. The waste management policy did not address the outdoor garbage disposal area, and no additional information was provided by the facility's administration before the exit conference.
The facility failed to ensure that three residents had the opportunity to develop advanced directives. One resident, who was cognitively intact, did not have any advanced directive documents in their clinical record and confirmed not receiving information about it. Another resident had an incomplete DNR order and no documentation of other advanced directives, despite facility policy requiring such information. A third resident, also cognitively intact, had a DNR status but no advance directive information, with no documented opportunity to complete one.
A facility failed to ensure an accurate MDS for a resident, incorrectly coding the discharge status as to a critical access hospital instead of home with family. The resident, who had diagnoses including UTI, sepsis, and dementia, was cognitively intact. A nurse confirmed the error and planned to correct it. The issue was discussed with the facility's administration.
The facility failed to complete Level I PASARRs for two residents with mental disorders, despite their policy requiring such screenings. One resident had severe cognitive impairment, while the other was cognitively intact. The absence of PASARRs was acknowledged by the Regional Nurse Consultant and Director of Nursing.
A resident with cognitive impairment and a history of traumatic brain injury required feeding assistance due to behaviors of eating too quickly. Despite an order for a dysphagia advanced texture diet and feeding assistance, the care plan lacked specific instructions, leading to a choking incident. The order was not transcribed to the Kardex, and CNAs were not informed of the resident's needs, resulting in inadequate supervision during meals.
A resident with multiple health conditions did not have their care plan reviewed and revised by the interdisciplinary team, resulting in unmet needs for meaningful activities. The facility failed to complete required activity progress notes and assessments, as admitted by the activity director, leading to a deficiency in care.
Two residents in the facility did not receive adequate ADL care, leading to deficiencies in personal hygiene. A resident with diabetes and cognitive impairment had long, jagged nails despite requesting care, while another resident with leukemia and arthritis went extended periods without showers or bed baths, potentially contributing to health issues. The facility's policy requires necessary ADL assistance, which was not consistently provided.
A resident with a stage IV pressure ulcer did not receive prescribed wound care on several occasions due to staff oversight when the wound nurse was off duty. The treatment administration record showed missed treatments, and the Director of Nursing confirmed the lapses, although the wound was reportedly improving.
A resident in a LTC facility did not receive adequate respiratory care due to the staff's failure to label and date oxygen extension tubing and provide a new pre-filled humidifier bottle. The resident, who was cognitively intact, was observed with an empty humidification bottle dated from over two months prior, and unlabeled tubing, contrary to medical orders and facility policy. The DON acknowledged the oversight, attributing it to the resident's late admission and use of an unused concentrator.
A resident with hypertension, congestive heart failure, and atrial fibrillation did not receive their prescribed Diltiazem medication due to unavailability in the medication cart and Cubex supply. An LPN attempted to obtain the medication from the pharmacy, but it did not arrive in time, leading to a physician's order to hold the dose. The facility's policy requires nurses to ensure medication availability, which was not met in this instance.
Two residents received insulin outside of physician-ordered parameters, despite being cognitively intact and having clear care plans. The facility's medication administration policy was not followed, leading to unnecessary medication administration. These issues were discussed with the facility's administration and nursing staff.
A resident with severe infections did not receive their prescribed Meropenem due to a lapse in medication administration. The resident's care plan required the medication, but it was not given as scheduled. The DON noted the medication might not have been available, and a staff change due to a COVID-19 case contributed to the oversight.
The facility failed to properly store and label food items, as observed during a survey. A cook/aide was unable to explain the dates on a jug of peeled garlic, leading to its disposal. Additionally, a container of yogurt with an expired date was found in a resident refrigerator and discarded. These actions were not in compliance with the facility's policies on food storage and labeling.
Failure to Prevent Foot Injuries Due to Inadequate Supervision and Hazard Control
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent an accident resulting in significant tissue injury to the bottom of a resident's feet. The resident, who had diagnoses including dementia, Alzheimer's disease, diabetes mellitus, peripheral neuropathy, and difficulty walking, was found with severe wounds on both feet, including blisters, missing skin, and bloody drainage. Staff interviews and clinical record reviews revealed that the resident had been observed propping his feet on heaters in the day room, sometimes with shoes on and sometimes off, over several days prior to the injury being discovered. Staff also reported that the resident was often resistive to care, wore shoes and socks for extended periods, and was known to pick at his feet, but these behaviors were not effectively monitored or addressed to prevent harm. The incident was first identified when a CNA alerted a nurse to the resident's leaking foot, prompting an assessment that revealed extensive skin damage. The nurse and other staff had not previously noticed the injury, and there was no documentation of regular or thorough foot checks despite the resident's high risk for skin breakdown and foot complications. The resident's care plan included interventions for skin integrity and resistance to care, but staff failed to ensure daily observation and timely reporting of abnormalities. Additionally, there was conflicting information regarding the cause of the injury, with some staff attributing it to burns from a heater and others to self-inflicted skin picking, compounded by the resident's inability to feel pain due to neuropathy. Medical evaluations, including those by the facility's medical director and external providers, noted uncertainty about the exact cause of the wounds, with some assessments suggesting burns and others indicating maceration and self-inflicted injury. Regardless of the etiology, the lack of adequate supervision and failure to prevent access to potential hazards, such as heaters, contributed to the resident sustaining serious injuries that required hospitalization and specialized burn care. The facility's documentation and staff interviews confirmed that the resident's behaviors and risk factors were known but not sufficiently managed to prevent the accident.
Medication and Equipment Management Deficiencies
Penalty
Summary
The facility staff failed to administer the medication carvedilol as per the physician's order for Resident #9. The resident, who is cognitively intact with a mental status score of 15 out of 15, has a care plan that includes administering medications as ordered for cardiovascular symptoms related to hypertension. However, the medication administration record for August 2024 showed a blank entry on one occasion and a hold code on another, without parameters to hold the medication for low blood pressure. The Director of Nursing confirmed that the medication was not administered, and the nurse involved could not recall if it was given. For Resident #63, the facility staff did not follow the medical provider's order to provide a functioning pressure redistribution mattress. The resident, who is also cognitively intact, reported that her air mattress was not working. Upon inspection, the mattress was found to be unplugged, and once plugged in, it began to function. The medical provider's order required a pressure redistribution mattress, and a subsequent order mandated checking its function every shift. The facility's policy on skin integrity and wound management was reviewed, which includes implementing pressure injury prevention. These deficiencies were discussed with the facility's administration and nursing staff, but no further information was provided before the survey exit. The issues highlight a failure to adhere to physician orders and ensure proper equipment functionality, impacting the care provided to the residents.
Supervision Failures Lead to Resident Harm and Elopement
Penalty
Summary
The facility staff failed to provide adequate supervision to prevent accidents for two residents, resulting in actual harm for one resident and an elopement incident for another. For the first resident, the facility staff did not follow the physician's orders and speech therapy recommendations for supervision during meal times. The resident, who had a history of Alzheimer's Disease, stroke, traumatic brain injury, and paranoid schizophrenia, was found unresponsive after being left unsupervised during breakfast. The resident required feeding assistance and supervision to prevent choking, as indicated by previous incidents and recommendations. However, these requirements were not properly documented or communicated to the staff, leading to the resident's death. In the case of the second resident, the facility staff failed to maintain a safe environment to prevent elopement. The resident, who had severe cognitive impairment and a history of wandering, was supposed to have a functioning wander guard device. However, the device was found to be ineffective, and the resident managed to elope from the facility. The resident was later found outside by the dumpsters, indicating a failure in monitoring and securing the resident's safety. The facility's records showed that the wander guard system was not properly checked, and there was no investigation or documentation of the incident available. Both incidents highlight significant lapses in the facility's supervision and safety measures, leading to severe consequences for the residents involved. The lack of proper documentation, communication, and adherence to care plans contributed to these deficiencies, resulting in harm and potential risk to the residents' safety.
Improper Disposal and Containment of Garbage
Penalty
Summary
The facility staff failed to ensure proper disposal and containment of garbage and waste in the designated disposal area. During an observation, surveyors noted scattered debris around two dumpsters located outside the facility on its campus. The debris included seven gloves, four Styrofoam cups, a large black trash bag with unknown contents, and four large pieces of brown wood, which an employee speculated might have been placed there by maintenance. The facility's waste management policy, reviewed by the survey team, did not address the garbage disposal area outside the facility. This issue was discussed with the Administrator, Director of Nursing, and Regional Nurse Consultant, but no further information was provided before the exit conference.
Failure to Ensure Residents' Opportunity to Develop Advanced Directives
Penalty
Summary
The facility staff failed to ensure that residents had the opportunity to develop an advanced directive, affecting three residents in the survey sample. Resident #32, who was cognitively intact, did not have any advanced directives, POST, POLST, or MOLST documents in their clinical record, despite a care plan indicating that advanced directive education and materials were provided. The resident confirmed in an interview that they did not have an advanced directive and were not given any written information about it. Resident #44, who had mild cognitive impairment, had a DNR order signed by a family member, but the form was incomplete as it lacked a mark in the checkbox indicating the resident's capability to make informed decisions. The clinical record did not contain any advanced directives, and the care plan only mentioned a DNR status without discussing other forms of advanced directives. The facility's policy required informing and providing written information to residents about their rights to accept or refuse treatment and formulate an advance directive, but this was not documented for Resident #44. Resident #39, who was cognitively intact, had a DNR status but no information related to an advance directive in their clinical record. The Social Services Assessment indicated that no additional conversation regarding advance care planning was provided, and the opportunity to complete an advance directive was not offered. The facility's policy emphasized the right of residents to participate in their healthcare decision-making and the requirement to inform them about advance directives, but this was not followed for Resident #39. The survey team discussed these concerns with the facility's administration, but no further information was provided before the exit conference.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility staff failed to ensure an accurate Minimum Data Set (MDS) for one of the closed record reviews, specifically for Resident #56. The MDS was incorrectly coded as the resident being discharged to a critical access hospital, while the resident was actually discharged to the community, specifically home with family. Resident #56's face sheet included diagnoses such as urinary tract infection, sepsis, and dementia. The discharge MDS, with an assessment reference date, indicated the resident was cognitively intact with a perfect score on the brief interview for mental status. However, the discharge status was inaccurately coded. A registered nurse confirmed the error and stated that the assessment would be modified to correct it. This issue was discussed with the facility's administrator, director of nursing, and regional nurse consultant.
Failure to Complete PASARR for Residents with Mental Disorders
Penalty
Summary
The facility staff failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was completed for two residents, leading to a deficiency. For one resident, who had diagnoses including Alzheimer's disease, dementia, and bipolar disorder, the clinical record lacked a Level I PASARR. The resident's cognitive impairment was severe, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Despite the facility's policy requiring social services to coordinate the PASARR process, the Regional Nurse Consultant admitted that the PASARR was not completed, acknowledging it as an issue. Similarly, another resident with diagnoses of bipolar disorder, anxiety disorder, and depression also did not have a Level I PASARR in their clinical record. This resident was cognitively intact, with a BIMS score of 14 out of 15, and showed no mood indicators or behaviors during the assessment period. The Director of Nursing and the Regional Nurse Consultant confirmed the absence of the PASARR, recognizing it as a problem. The facility's policy mandates that all patients with mental disorders or intellectual disabilities receive appropriate pre-admission screenings, but this was not adhered to in these cases.
Failure to Implement Comprehensive Care Plan Leads to Choking Incident
Penalty
Summary
The facility staff failed to develop and implement a comprehensive person-centered care plan for a resident with multiple diagnoses, including Alzheimer's, a history of stroke, traumatic brain injury, and paranoid schizophrenia. The resident had a moderate cognitive impairment and required feeding assistance due to behaviors related to eating too quickly. Despite an order from the speech therapist for a dysphagia advanced texture diet and feeding assistance, the care plan did not specify the diet or the need for feeding assistance. This omission led to a critical incident where the resident choked on a piece of bread, requiring emergency intervention. The deficiency was further compounded by a lack of communication and documentation. Staff interviews revealed that the order for feeding assistance was not transcribed to the Kardex, and the CNAs were not adequately informed or educated about the resident's needs. The CNA who provided the resident's meal tray was unaware of the requirement for feeding assistance, as it was not documented in the Kardex. The facility's process for updating care plans and communicating dietary needs was not followed, resulting in a failure to provide the necessary supervision and cuing for the resident during meals.
Failure to Review and Revise Resident's Care Plan
Penalty
Summary
The facility staff failed to ensure the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team. The resident, who had multiple diagnoses including Anxiety Disorder, Cirrhosis of the Liver, and End Stage Renal Disease, expressed that the activities offered did not include one-to-one activities in her room. The care plan, which was last revised without changes, did not reflect the resident's current needs or preferences for activities. Additionally, there were no activity progress notes or an annual activity assessment found in the clinical record for the resident. The activity director admitted to not completing activity progress notes every ninety days or with care plan reviews, and was unaware of the facility's policy regarding these notes. The facility's policy requires annual recreation assessments and quarterly progress notes to document the effectiveness of interventions and review the resident's progress. However, these were not completed for the resident, leading to a deficiency in meeting the resident's needs for meaningful activities.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care for two residents, leading to deficiencies in personal hygiene. Resident #7, who has diagnoses including type 2 diabetes mellitus, anxiety, and depression, was observed with long and jagged nails, including a broken nail. Despite being dependent on staff for personal hygiene due to moderate cognitive impairment, the resident reported that their requests for nail care were not addressed until after the surveyor's intervention. The facility's policy mandates that residents unable to perform ADLs receive necessary assistance to maintain grooming and hygiene, which was not initially provided for Resident #7. Resident #39, diagnosed with myeloid leukemia, polyosteoarthritis, and depression, reported going extended periods without showers or bed baths, which they felt contributed to urinary tract infections. The resident, who is cognitively intact but requires substantial assistance for bathing, experienced multiple instances where they went several days without receiving a shower or bed bath, as documented in the facility's records. The facility's policy requires that residents receive the necessary level of ADL assistance to maintain personal hygiene, which was not consistently provided for Resident #39.
Failure to Administer Prescribed Wound Care
Penalty
Summary
Facility staff failed to provide adequate treatment and services to prevent and heal pressure ulcers for one resident in the survey sample. The resident, who had a stage IV pressure ulcer in the sacral region, was noted to have a care plan that included wound care per treatment order. However, there were documented lapses in the administration of the prescribed wound care treatment. Specifically, the treatment administration record (TAR) showed blanks on several dates, indicating that the wound care was not performed as ordered on those days. The Director of Nursing (DON) confirmed that the wound nurse was off on the days when the treatment was missed, and the floor staff, who were responsible for completing the treatments in the nurse's absence, did not perform the necessary care. Despite the DON's statement that the wound was improving, the failure to administer the prescribed wound care on the specified dates was acknowledged. This issue was discussed with the survey team, but no further information was provided before the exit conference.
Inadequate Respiratory Care Due to Improper Oxygen Equipment Management
Penalty
Summary
The facility staff failed to provide adequate respiratory care for a resident by not labeling and dating each component of the oxygen extension tubing and not providing a new pre-filled humidifier bottle upon utilization of the oxygen concentrator. The resident, who was cognitively intact with a BIMS score of 15 out of 15, was observed by a surveyor to be on oxygen via nasal cannula with the concentrator set at 2 liters. The humidification bottle was found to be empty and dated from over two months prior, and the oxygen extension tubing lacked a label or date. The medical provider's orders required oxygen at 2 liters per minute via nasal cannula continuously, with instructions to label each component with the date and initials. The LPN confirmed the surveyor's observations of the outdated humidification bottle and unlabeled tubing. The DON acknowledged the oversight, attributing it to the resident's late evening admission and the use of a concentrator that was not in use. The facility's policy outlined the procedure for oxygen concentrator setup, including labeling and dating the humidifier bottle, which was not followed in this instance.
Medication Unavailability for Resident with Cardiovascular Conditions
Penalty
Summary
The facility staff failed to ensure that the medication Diltiazem was available for administration to a resident diagnosed with hypertension, congestive heart failure, and atrial fibrillation. During a medication pass, an LPN discovered that Diltiazem was not in the medication cart and attempted to retrieve it from the Cubex emergency medication supply, but it was unavailable. Consequently, the LPN had to contact the pharmacy for a stat order, but the medication did not arrive in time for administration. The resident's clinical record confirmed a physician's order for Diltiazem to be administered once daily. Due to the unavailability of the medication, the LPN obtained an order from the physician to hold the medication for one dose. The facility's policy on medication shortages emphasizes the nurse's responsibility to ensure medications are available to meet residents' needs. This deficiency was discussed with the facility's administrator, director of nursing, and regional nurse consultant.
Failure to Adhere to Insulin Administration Parameters
Penalty
Summary
The facility staff failed to ensure that two residents were free from unnecessary medications. For one resident, insulin was administered outside the physician-ordered parameters. This resident had a diagnosis of type 2 diabetes mellitus, among other conditions, and was cognitively intact. The resident's care plan included monitoring blood glucose levels and administering insulin as per medical orders. However, the medication administration record showed that insulin was given even when blood sugar levels were below the specified threshold, contrary to the physician's orders. Another resident also received insulin outside the prescribed parameters. This resident had multiple diagnoses, including type 2 diabetes mellitus and chronic kidney disease, and was also cognitively intact. The resident's medication regimen review indicated that insulin should be held if blood sugar was below a certain level. Despite this, the medication administration record revealed that insulin was administered on several occasions when the blood sugar was below the specified threshold. The facility's policy on medication administration requires that medications be administered as prescribed and in accordance with written orders. However, in both cases, the facility staff did not adhere to these guidelines, leading to the administration of unnecessary medications. These concerns were discussed with the facility's administration and nursing staff, but no further information was provided before the survey exit.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility staff failed to administer the medication Meropenem to a resident as per the physician's orders. The resident, who was cognitively intact, had a comprehensive care plan that included administering medications as ordered due to their diagnoses, which included sepsis, severe sepsis with septic shock, necrotizing fasciitis, MRSA, ESBL resistance, and pseudomonas. The physician's order specified that Meropenem should be administered intravenously every 8 hours for 28 days. However, the electronic medication administration record (eMAR) showed that the medication was not administered on the morning of August 12, 2024. The Director of Nursing (DON) acknowledged the omission, suggesting that the medication might not have been available and a hold order should have been written. The situation was further complicated by the night shift nurse testing positive for COVID-19, leading to a change in staff. The incoming nurse was unsure if the Meropenem had been administered and therefore did not give it. The facility's policy on medication administration requires that medications be administered as prescribed, but this was not followed in this instance.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility staff failed to appropriately store, prepare, and serve resident food items, as observed during a survey. During an initial tour of the dietary department, a surveyor found a plastic jug labeled 'peeled garlic' in the walk-in cooler with multiple dates written on the lid, including an illegible date. The employee identified as a cook/aide, who was in charge in the absence of the dietary manager, was unable to clearly explain the significance of the dates and decided to discard the item. The facility's policy on refrigerated/frozen storage required all foods to be labeled with the product name, date received, and use-by date once opened, which was not adhered to in this instance. Additionally, a surveyor found a 6-ounce container of vanilla yogurt in the resident refrigerator on the North wing with a handwritten date of 7/31/24 on the lid, while the factory-stamped expiration date was 8/14/24. The yogurt was discarded after notifying the Dietary Manager. The facility's policy on storing food brought in for residents required that food be held in the refrigerator for three days following the date on the label and discarded by staff upon notification to the resident. These findings were discussed with the Administrator, Director of Nursing, and Regional Nurse Consultant, but no further information was provided before the exit conference.
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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.
Illustrative
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Illustrative
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Nursing homes near Bluefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercer Healthcare Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Bluestone Health And Rehabilitation | 1.8 mi | ★★★★★ | 15 | 1 |
| Bland County Nursing & Rehab Center | 7 mi | ★★★★★ | 5 | 0 |
| Glenwood Healthcare Center | 8.2 mi | ★★★★★ | 0 | 0 |
| Princeton Health Care Center | 10.3 mi | ★★★★★ | 10 | 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.