Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westridge Health Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain sufficient dietary staffing as outlined in its facility assessment, resulting in one Dietary Manager functioning as the sole cook for extended periods, working very long shifts with minimal support. During meal observations, only two dietary staff were present, and the cook was unable to honor a resident’s request for an additional food item due to time constraints while preparing all trays. Several residents reported that food quality had declined, meals were repetitive or late, and alternatives were not offered, which they linked to having only one cook. Review of staffing schedules confirmed a prolonged pattern of understaffing in the kitchen, including days with only one staff member and no separate cook scheduled.
An LPN was observed pre-pouring medications for multiple residents, handling pills with bare hands, and preparing medication cups in advance, resulting in missing prescribed medications for several residents. One resident and his sister reported incidents where the wrong medications were nearly administered. These actions were in direct violation of facility policy, which prohibits pre-pouring and requires medications to be prepared immediately prior to administration and not handled with bare hands.
An LPN was observed preparing medications by dispensing pills into her bare hands and placing them into medication cups, including picking up a dropped pill from the desk surface with bare hands. This practice was in direct violation of facility policy, which prohibits handling medications with hands, as confirmed by the DON and Nurse Consultant.
Two residents in an LTC facility did not receive showers or bed baths as per their preferences due to staffing challenges and inconsistent documentation. One resident, who required assistance, missed several scheduled bed baths, while another received fewer showers than scheduled, with no documented refusals. Staff interviews revealed inconsistencies in documentation practices, contributing to the deficiency.
The facility failed to dispose of expired insulin for two residents, as found during an inspection. Expired insulin vials and a pen were discovered on a medication cart and in a storage room, respectively. The facility's policy requires multi-dose vials to be discarded within 28 days, which was not followed.
The facility failed to label and date refrigerated and frozen food items properly, leading to potential contamination and spoilage. Observations revealed undated food items and water dripping onto food in the refrigerator. The Dietary Manager could not identify the water source, and the facility's storage guidelines were not followed.
A facility failed to document timely communication with a hospital prior to a resident's transfer. The resident, with COPD, cerebral infarction, and late-onset Alzheimer's, was hospitalized but lacked initial documentation of contact with the hospital ER. A late entry note was added later as a correction, indicating the family and ER were notified, which deviated from the facility's documentation policy.
A facility failed to properly handle a glucometer during blood glucose monitoring for two residents with type 2 diabetes. A QMA placed the glucometer directly on side tables without a barrier, contrary to facility policy. The glucometer was then returned to its case and the medication cart. Interviews revealed that the glucometer should have been placed on a paper towel to prevent cross-contamination.
The facility failed to update care plans with post-fall interventions for four residents reviewed for falls. A resident with a history of hemiplegia and dementia experienced multiple falls, including one requiring ER treatment, but care plans lacked immediate interventions. Another resident fell from a wheelchair without documented interventions, and a third resident's recent fall was not documented. A fourth resident reported falls without injury, but care plans lacked immediate interventions. Staff interviews revealed uncertainty about care plan updates, and the facility's policy was not effectively implemented.
The facility failed to ensure proper handling of clean and soiled linens. Staff members were observed carrying clean linens against their bodies and transporting soiled linens unbagged, contrary to the facility's infection control policy.
A facility failed to ensure a call light device was within reach for a resident with significant physical limitations. The resident's call light was repeatedly observed to be out of reach, forcing her to ask for help when staff entered her room. The DON acknowledged the issue and confirmed that the call light should not have been placed on the wall. The facility's policy required call lights to remain functional and within reach, which was not adhered to in this case.
A facility failed to ensure that pressure ulcer treatments were completed by qualified staff for a resident with a stage III pressure ulcer. Despite facility policy and state regulations, QMAs performed dressing changes beyond their scope of practice. Medical records and interviews confirmed that QMAs documented completing these tasks, which should have been performed by licensed nurses.
The facility failed to provide treatment to prevent further decrease in range of motion for a resident with a contracted left hand. Despite a referral for evaluation, no anti-contracture device was in place, and no treatment order was obtained. The care plan required range of motion exercises and repositioning, but these interventions were not documented or followed.
The facility failed to ensure the dish machine wash temperature met the required range, with observations showing a maximum of 80°F, below the manufacturer's guideline of 120-140°F. The Dietary Manager confirmed the discrepancy, despite logs inaccurately documenting compliant temperatures.
Inadequate Dietary Staffing Leading to Poor Food Quality and Service
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient food and nutrition services staff as outlined in its own facility assessment, which called for a director and three food and nutrition services staff. Surveyors reviewed a confidential statement indicating that the food from the kitchen was described as disgusting and that there were not enough kitchen workers. During a lunch observation, only two dietary staff were present: the Dietary Manager, who was also the cook, and a Dietary Aide. The Dietary Manager was the only person plating food for both the dining room and hall trays and was unable to provide an additional food item requested by a resident, stating she did not have time because she needed to prepare all the hall trays. Multiple residents reported concerns about food quality and lack of alternatives, which they attributed to insufficient kitchen staffing. One resident stated that the food had gone downhill, was repetitive, and not worth eating, and commented that there was only one cook who could not manage all the work. Another resident reported that the food was terrible and that no alternatives were offered because there was only one cook who did not have time to prepare other options. A third resident reported that meals were often late and that food quality had declined, acknowledging that there was only so much one person could do. Interviews and schedule reviews showed that the Dietary Manager had effectively been working as the only cook for an extended period. The Administrator stated the facility should have a full-time Dietary Manager, day cook, evening cook, and dishwasher, and that other non-dietary staff could help in the kitchen if needed. The Dietary Manager reported she had been performing manager duties since August 2025, had been prepping, cooking, and cleaning up all meals daily, working approximately 14 hours a day, 7 days a week, and had worked over 30 days without a day off. She also reported not being trained on the computer system for ordering food and lacking time to properly clean the kitchen or begin ServSafe certification. Review of dietary schedules over several weeks showed repeated days with only two staff in the kitchen, the Dietary Manager consistently working 13–14 hour shifts, and at least one day with only one staff member in the kitchen and no cook scheduled, demonstrating a sustained pattern of inadequate staffing relative to the facility’s own assessment.
Failure to Ensure Safe and Accurate Medication Administration
Penalty
Summary
The facility failed to ensure safe and accurate medication administration for four residents, as observed during a random medication pass. An LPN was seen preparing multiple residents' medications in advance by dispensing pills from medication cards into her bare hands and placing them into medication cups, which were then stacked and labeled with residents' initials. The LPN dropped a pill onto the desk, picked it up with her bare hands, and placed it back into a medication cup. The medications were prepared ahead of time for later administration, and several medication cups were missing required medications according to the residents' electronic Medication Administration Records (eMARs). Further review revealed that the LPN had not included all prescribed medications in the cups for several residents. For example, one resident's cup was missing clonidine, another was missing magnesium oxide, primidone, and sertraline, and a third was missing atorvastatin, buspirone, gabapentin, pramipexole, sertraline, and tizanidine. Additionally, a resident reported that the LPN had attempted to give him the wrong medications on two separate occasions in the dining room, which was corroborated by his sister. The LPN admitted to setting down the wrong medication cups but claimed to have caught the errors before administration. The facility's policy, revised in 2017, explicitly stated that medications should never be pre-poured, should not be touched with bare hands, and must be prepared just prior to administration. The policy also required staff to observe residents taking their medications. Despite this, the LPN pre-poured medications for multiple residents, handled pills with bare hands, and failed to ensure the correct medications were prepared and administered as ordered.
Improper Medication Handling During Medication Pass
Penalty
Summary
During a random observation, an LPN was seen preparing medications at the nurses' station by dispensing pills from medication cards directly into her bare hands and then placing them into medication cups. The LPN also picked up a pill that had fallen onto the desk surface with her bare hands and placed it into a medication cup. When questioned, the LPN stated she was unaware this was an issue after washing her hands. Facility policy, as provided by the DON, clearly states that medications should never be touched with hands during administration. The Nurse Consultant confirmed that at no time should medications be handled with bare hands.
Failure to Provide Scheduled Showers and Bed Baths
Penalty
Summary
The facility failed to ensure that residents were provided with showers or bed baths according to their preferences, as evidenced by the cases of two residents. Resident 41, who was cognitively intact and required assistance with activities of daily living, expressed that he preferred to receive bed baths twice a week in the evenings. However, due to staffing challenges, he often did not receive these baths as scheduled, with documentation showing missed baths on several occasions. Interviews with staff confirmed the difficulty in completing all tasks due to insufficient staffing, and the facility was unable to provide documentation to support that the baths were administered as scheduled. Similarly, Resident 40, who was also cognitively intact and required assistance with bathing, reported not receiving regular showers as per his preference for two showers per week in the evenings. The facility's records indicated that the resident received fewer showers than scheduled, and there was a lack of documentation regarding any refusals of care. Interviews with CNAs and the DON revealed inconsistencies in documentation practices, with some staff unaware of any refusals by the resident, while others mentioned the use of behavior sheets for refusals, which were not consistently documented in the medical record. The facility's failure to adhere to residents' preferences for personal hygiene care, as well as the lack of consistent documentation and communication among staff, contributed to the deficiency. The facility's policy on resident rights emphasized the importance of treating residents with respect and dignity, yet the documentation and interviews highlighted a gap in fulfilling these rights, particularly in maintaining the residents' quality of life through their preferred care routines.
Expired Medications Not Disposed of Properly
Penalty
Summary
The facility failed to ensure the proper disposal of expired medications, specifically insulin, for two residents. During an inspection, surveyors found two expired insulin vials on the south hall medication cart, which were labeled for a resident with type 2 diabetes mellitus with hyperglycemia. The insulin vials had an open date of over 30 days prior, exceeding the recommended usage period. A Qualified Medication Aide confirmed that the insulin should have been discarded after 30 days of being opened. Additionally, an expired insulin pen was found in the north hall medication storage room, labeled for another resident with type 2 diabetes mellitus without complications. The insulin pen had an open date of over 28 days prior, and a Qualified Medication Aide was unsure why it was not discarded. The facility's policy, provided by the Corporate Nurse Consultant, indicated that multi-dose vials like insulin should be discarded within 28 days unless specified otherwise by the manufacturer. These findings indicate a failure to adhere to the facility's medication expiration policy.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to properly label and date refrigerated and frozen food items, which is necessary to ensure they are used by their use-by date, frozen, or discarded appropriately. During an initial kitchen observation, tomatoes and lettuce in the main refrigerator were found with an opened date of 2/24, and water was observed dripping onto a covered container of chicken noodle soup. Additionally, the bottom of the refrigerator had water, causing boxed food items to become wet. In the freezer, several items, including tater tots, pie shells, cakes, and pies, were found undated, indicating a lack of adherence to proper food storage guidelines. Further observations revealed standing water on the top shelf of sealed food items in the refrigerator, which spilled onto the floor when moved. The Dietary Manager was unable to identify the source of the water. The facility's storage guidelines, provided by the Administrator, indicated specific storage durations for various food items, which were not followed. This lack of compliance with food storage standards poses a risk of food contamination and spoilage.
Failure to Document Timely Hospital Transfer Communication
Penalty
Summary
The facility failed to ensure timely documentation of contact with the hospital prior to the transfer of a resident, identified as Resident 31, who was hospitalized. The resident's medical history included chronic obstructive pulmonary disease (COPD), cerebral infarction, and late-onset Alzheimer's disease. The resident was noted to have a moderate cognitive deficit, was totally dependent on all activities of daily living, and required continuous oxygen. The resident was hospitalized from March 9 to March 13, 2025, but the initial review of the record lacked documentation of the facility's contact with the hospital emergency room to provide a report of the transfer. A follow-up review revealed a late entry progress note dated March 18, 2025, for the transfer date of March 9, 2025, indicating that the family and emergency room had been notified. This note was added as a plan of correction after it was discovered that no note had been written at the time of the transfer. The facility's policy, provided by the Administrator, required nurse's notes to be written on each resident, addressing the resident's conditions and any pertinent change in condition, and to document significant information. The failure to document the transfer in a timely manner was a deviation from this policy.
Improper Handling of Glucometer During Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure proper handling of the glucometer during blood glucose monitoring for two residents. During observations, a Qualified Medication Aide (QMA) placed the glucometer directly onto the side tables of Residents 42 and 35 without using a barrier, such as a paper towel, as required by the facility's policy. This action was observed during two separate blood glucose monitoring opportunities. The glucometer was then returned to a resident-specific black case and placed back in the medication cart without proper barrier protection. Resident 42 has a diagnosis of type 2 diabetes mellitus with hyperglycemia, while Resident 35 has type 2 diabetes mellitus without complications. During an interview, QMA 7 mentioned that the night shift nurses clean the glucometers, and she also cleans them at the end of her shift. However, QMA 10 later indicated that a paper towel should be placed under the glucometer to prevent cross-contamination, which was not done in these instances. The facility's policy, provided by the Corporate Nurse Consultant, clearly states that a clean paper towel should be used as a barrier when placing the glucometer on a surface.
Failure to Update Care Plans with Post-Fall Interventions
Penalty
Summary
The facility failed to update care plans with post-fall interventions for four residents reviewed for falls. Resident A, who has a history of hemiplegia, vascular dementia, and aphasia, experienced multiple falls, including one that resulted in a head laceration requiring emergency room treatment. Despite these incidents, the care plans lacked evidence of immediate post-fall interventions and did not document the level of assistance required for transfers and mobility. Interventions such as moving the resident's room closer to the nurses' station and using alarms were noted, but there was no documentation of monitoring or specific interventions related to the root causes of the falls. Resident C's medical record indicated a fall from a wheelchair, but the care plan lacked evidence of immediate post-fall interventions. Although interventions like anti-rollbacks for the wheelchair and frequent reminders were documented, there was no documentation of interventions related to the root causes of the falls. Similarly, Resident H's record lacked documentation of a recent fall, and the care plan did not include immediate post-fall interventions, despite the resident being at risk for falls. Resident K, who reported three falls without injury, had a care plan indicating a risk for falls, but the record lacked documentation of immediate post-fall interventions. Interviews with facility staff revealed uncertainty about who was responsible for updating care plans, and the facility's policy on care plan development and review was not effectively implemented. The interdisciplinary team was supposed to update care plans after each fall, but this was not consistently done, leading to deficiencies in the care provided to residents at risk of falls.
Improper Handling of Clean and Soiled Linens
Penalty
Summary
The facility failed to ensure proper handling of clean and soiled linens during multiple observations. Certified Nursing Assistant (CNA) 21 was observed on several occasions retrieving clean linens from the linen closet and transporting them against her body to various locations, including resident rooms and a shower room. Similarly, Employee 3 was seen carrying soiled linens unbagged against her body while wearing gloves, and indicated she needed to take the linens to the hopper. These actions were contrary to the facility's policy, which mandates that clean linens should not be carried against the body and soiled linens should be placed in a container before being transported in the hallway. Interviews with staff members, including Employee 8 and CNA 22, confirmed that the proper procedure for handling linens was not followed. Employee 8 indicated that staff were not supposed to carry linens against their body, and soiled linens were to be transported in a plastic bag. CNA 22 also confirmed that dirty linens should be bagged before being taken to the hopper room and that clean linens should be held away from the body. The facility's policy, provided by the Regional Nurse Consultant, clearly stated that linens should be handled in a manner to prevent the spread of infection, including not carrying clean linens against the body and placing soiled linens in a container before transporting them in the hallway.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a call light device was within reach for a resident, leading to a deficiency. On multiple occasions, the resident's call light was observed to be draped on an outlet against the wall and out of reach. The resident, who had significant physical limitations and required assistance for turning and repositioning in bed, indicated that staff had recently stopped providing her with a call light, forcing her to ask for help when staff entered her room. The resident's medical history included right and left knee contractures, muscle weakness, stiffness of the left hand, and gastrostomy status. She was cognitively intact but had functional limitations in both upper and lower extremities and moderately impaired vision. During an interview, the DON acknowledged that the resident did not use her call light often and was not ordered to have a soft touch call light. However, upon observation, the DON confirmed that the call light should not have been placed on the wall and subsequently placed it within the resident's reach. The facility's policy, dated 10/2014, stated that call lights must remain functional and within reach of each resident, and must not be disabled or removed from the resident's reach. Despite this policy, the call light was repeatedly found out of reach, indicating a failure to accommodate the resident's needs and preferences.
Failure to Ensure Qualified Staff Perform Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed by qualified staff and that proper standards of practice were followed for a resident with a stage III pressure ulcer. Resident 29, who had a history of stage IV pressure ulcers and was diagnosed with Type 2 diabetes mellitus and chronic obstructive pulmonary disease, reported having an open area on his bottom for a few months. Interviews revealed that Qualified Medication Aides (QMAs) were performing dressing changes on the resident's pressure ulcer, which is beyond their scope of practice as per facility policy and state regulations. The resident's medical records indicated that the pressure ulcer was being treated with specific physician-ordered dressings. However, documentation showed that QMAs were completing these dressing changes on multiple occasions, despite the facility's policy that only licensed nurses should perform such tasks. The Director of Nursing and other staff members confirmed that QMAs are not permitted to perform dressing changes on wounds greater than stage I, and acknowledged that QMAs had been signing off on these tasks in the Medication Administration Records (MARs). The facility's policies, including the Qualified Medication Aide Scope of Practice and Job Description, explicitly state that QMAs are not allowed to administer treatments for advanced skin conditions, including stage II, III, and IV pressure ulcers. Despite this, the MARs for December 2023, January 2024, and February 2024 showed multiple instances where QMAs documented completing dressing changes for Resident 29's stage III pressure ulcer. The Regional Nurse Consultant and the Director of Nursing were aware of this issue and indicated that the QMAs would be educated on their scope of practice.
Failure to Prevent Decrease in Range of Motion
Penalty
Summary
The facility failed to provide treatment to prevent further decrease in range of motion for a resident with a contracted left hand. During multiple observations, the resident was seen sitting in a wheelchair with the left hand contracted in a fist position and no anti-contracture device in place. Interviews with the Director of Nursing (DON) and the Certified Occupational Therapy Assistant (COTA) revealed that although a referral for evaluation was made, the evaluation had not been completed, and no treatment order had been obtained. The COTA acknowledged receiving the referral but had not yet conducted the evaluation. The Regional Nurse Consultant also confirmed that an order for evaluation was discussed but not obtained. The resident's medical record indicated diagnoses including hemiplegia, hemiparesis, muscle weakness, and other conditions. The care plan noted the resident was at risk for complications related to hemiplegia/hemiparesis and required range of motion exercises and repositioning of affected limbs. However, there was no documentation of orders for range of motion or prevention of contractures, and the care plan interventions were not being followed. The facility's policy on joint mobility screening outlined procedures for identifying residents at risk for contractures and recommended interventions, but these were not implemented for the resident in question.
Dish Machine Temperature Non-Compliance
Penalty
Summary
The facility failed to ensure the wash temperature of the chemical sanitizing dish machine met the required temperature during a kitchen observation. During the initial kitchen tour, the dish machine temperature dial indicated a top temperature of 80 degrees Fahrenheit during the wash cycle, which was below the required range of 120-140 degrees Fahrenheit as per the manufacturer's guidelines. Four separate wash cycles were attempted, none of which reached a temperature higher than 80 degrees Fahrenheit. The Dietary Manager confirmed this with a manual thermometer and acknowledged that the minimum temperature should be between 100 and 120 degrees Fahrenheit. Despite this, the dish machine temperature logs for February 2024 inaccurately documented the wash temperature as 100 degrees Fahrenheit for all days of the month, indicating a discrepancy between recorded and actual temperatures.
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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 Terre Haute
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Village Health & Rehab | 1.1 mi | — | 1 | 0 |
| Springhill Village | 1.7 mi | — | 5 | 0 |
| Southwood Healthcare Center | 1.9 mi | — | 22 | 2 |
| Majestic Care Of Deming Park | 3.3 mi | — | 4 | 2 |
| Harrison's Crossing Health Campus | 3.5 mi | — | 2 | 0 |
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