Inspection Reports for
Westhampton Care Center
78 Old Country Road, Westhampton, NY, 11977
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Inspection Report — Jun 10, 2025
Annual Inspection CMS
Date: Jun 10, 2025
Visit Reason
The inspection was a Recertification Survey conducted from 6/3/2025 to 6/10/2025 to assess compliance with regulatory requirements for nursing home certification.
Findings
The facility was found deficient in multiple areas including failure to develop a comprehensive care plan addressing a resident's visual impairment, improper storage and administration of medications, inadequate monitoring of cold food temperatures, and failure to maintain an effective infection prevention and control program, specifically regarding contact precautions for a resident with MRSA.
Citations (4)
F 0656: The facility did not develop or implement a comprehensive care plan with measurable objectives and timeframes to address a resident's visual impairment due to legal blindness and glaucoma.
F 0761: The facility failed to ensure all biologicals were stored in locked compartments; a resident had discontinued Flonase nasal spray at bedside without physician order or assessment for self-administration.
F 0812: The facility did not have a system in place to monitor temperatures of cold food items, risking food safety.
F 0880: The facility did not maintain an infection prevention program; contact precaution signage was not conspicuous and visitors entered a resident's room with MRSA without proper protective equipment.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 3
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #2 | Registered Nurse Unit Manager | Interviewed regarding care plan development for Resident #143's visual impairment |
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding responsibility for care plan initiation and infection control practices |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding medication storage and administration for Resident #12 |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding medication storage for Resident #12 |
| Food Service Director | Food Service Director | Interviewed regarding food temperature monitoring |
| Administrator | Administrator | Interviewed regarding food safety monitoring |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed and interviewed regarding visitor compliance with contact precautions for Resident #88 |
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding contact precaution signage for Resident #88 |
| Infection Preventionist #1 | Infection Preventionist | Interviewed regarding infection control signage and PPE requirements |
| Attending Physician | Attending Physician | Interviewed regarding medication orders for Resident #12 |
Inspection Report — Jun 10, 2025
Original Licensing State
Date: Jun 10, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from June 2022 to May 2026 with citation and enforcement history.
Complaint Details
The state logged 23 complaints about this facility; 7 led to on-site inspections. Two citations resulted from those complaints.
Findings
Across 8 inspections, 3 resulted in citations totaling 21 deficiencies primarily related to standard health and life safety code issues, all with minor potential harm. The facility had 23 complaints with 7 on-site inspections and 2 formal enforcement actions with fines totaling $24,000.
Citations (13)
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan deficiencies noted in multiple inspections.
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve sanitary violations found in multiple inspections.
Standard Health Citation — quality of care: Infection Prevention & Control issues identified.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals not compliant.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General deficiencies found.
Life Safety Code Citation — NFPA requirements: Physical Environment issues noted.
Standard Health Citation — quality of care: Notify Of Changes (injury/decline/room, Etc.) not properly done.
Standard Health Citation — quality of care: Quality Of Care deficiencies identified.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights violations found.
Standard Health Citation — quality of care: Self-determination issues noted.
Life Safety Code Citation — NFPA requirements: Exit Signage not compliant.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing deficiencies found.
Standard Health Citation — quality of care: Reporting Of Alleged Violations not properly conducted.
Report Facts
Inspections on page: 8
Total violations/deficiencies cited: 21
Inspections with violations: 3
Inspections without violations: 5
Total complaints: 23
On-site complaint inspections: 7
Citations issued from complaints: 2
Enforcement actions: 2
Total fines: 24000
Inspection Report — Jan 11, 2024
Annual Inspection CMS
Date: Jan 11, 2024
Visit Reason
The inspection was a Recertification survey conducted from 1/3/2024 to 1/11/2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and self-determination, notification of medication changes, incomplete care plans for diabetes management, inadequate intravenous catheter care, and improper food storage practices.
Citations (6)
F 0550: The facility failed to ensure resident dignity when Licensed Practical Nurse #2 responded to Resident #12's call bell in an undignified manner and denied removal of heel booties causing resident distress.
F 0561: The facility did not promote resident self-determination when Licensed Practical Nurse #2 denied Resident #12's request to remove heel booties without explanation or exploring alternatives.
F 0580: The facility failed to notify Resident #149 or their representative of a medication change when Heparin was discontinued due to a drug interaction with Aspirin.
F 0656: The facility did not implement a complete care plan for Resident #81 with diabetes, failing to document blood sugar monitoring from 12/15/2023 through 1/8/2024 as ordered.
F 0684: The facility failed to provide appropriate treatment for Resident #136 with a PICC line by not documenting weekly measurements of catheter length and arm circumference for three of four weeks in December 2023.
F 0812: The facility did not ensure food was stored and labeled properly; multiple trays of desserts and nourishments in the refrigerator were undated and unlabeled, preventing determination of safe consumption time.
Report Facts
Medication Administration Record missing documentation days: 25
Treatment Administration Record missing documentation days: 3
Number of trays of undated desserts/nourishments: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Named in findings related to undignified resident interaction and denial of resident's request to remove heel booties | |
| Registered Nurse #4 | Charge Nurse | Intervened to remove heel booties and educated resident and staff |
| Director of Nursing Services | Interviewed regarding nursing staff conduct and care plan deficiencies | |
| Registered Nurse #1 | Interviewed about notification of medication changes for Resident #149 | |
| Physician #1 | Interviewed about medication notification and resident capacity | |
| Licensed Practical Nurse #1 | Interviewed about blood sugar monitoring for Resident #81 | |
| Registered Nurse #5 | Supervisor | Interviewed about PICC line care documentation for Resident #136 |
| Physician #2 | Interviewed about importance of PICC line measurements | |
| Director of Food Services | Interviewed about food storage and labeling deficiencies | |
| Dietary Aide #1 | Interviewed about dessert preparation and labeling practices | |
| Dietary Aide #2 | Interviewed about dessert storage and labeling practices |
Inspection Report — Jul 17, 2023
Abbreviated Survey CMS
Date: Jul 17, 2023
Visit Reason
The visit was conducted as an abbreviated survey triggered by complaint #NY00304903 to investigate allegations of abuse at the facility.
Complaint Details
The complaint investigation was based on allegation #NY00304903. The allegation of sexual abuse was unsubstantiated after investigation due to inconsistent resident statements and psychiatric history. The allegation was not reported to the Department of Health as it was deemed not reasonable.
Findings
The facility failed to timely report an alleged sexual abuse case involving one resident to the New York State Department of Health within the required time frames. The allegation was investigated and found to be unsubstantiated due to inconsistent statements and the resident's psychiatric history.
Citations (1)
F 0609: The facility did not ensure that all alleged violations involving abuse were reported immediately but no later than 2 hours after the allegation was made to the appropriate officials. Specifically, an alleged sexual abuse case was not reported within required time frames.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Named in documentation of the sexual abuse allegation report. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in documentation of the sexual abuse allegation report. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Alleged perpetrator in the sexual abuse allegation. |
| Director of Nursing Services | Director of Nursing Services | Conducted investigation and provided statements regarding the allegation. |
| Social Worker #1 | Social Worker | Spoke to the resident during the investigation. |
| Administrator #1 | Administrator | Interviewed and stated the allegation was unsubstantiated. |
Inspection Report — Jan 18, 2022
Complaint Investigation CMS
Date: Jan 18, 2022
Visit Reason
The inspection was conducted as a Recertification Survey and Abbreviated Survey triggered by complaints regarding failure to notify family of treatment changes, failure to report abuse/neglect, inadequate treatment and care, inadequate supervision to prevent accidents, and infection control deficiencies.
Complaint Details
The complaint investigations included failure to notify family of medication changes for Resident #314, failure to report abuse/neglect related to Resident #364's fall, inadequate psychiatric care for Resident #314, inadequate supervision leading to Resident #364's fall and injury, and infection control breaches including improper PPE use by staff and family members.
Findings
The facility failed to notify Resident #314's family of significant medication changes, failed to report a fall with injury of Resident #364 to the state, did not provide appropriate psychiatric consultation and care for Resident #314, failed to provide adequate supervision and assistance to prevent Resident #364's fall, and failed to implement proper infection prevention and control measures including PPE use by staff and family members.
Citations (5)
F 0580: The facility failed to immediately notify Resident #314's family of a significant change in treatment involving a gradual dose reduction of antipsychotic medication Seroquel.
F 0609: The facility failed to timely report suspected neglect when Resident #364 fell from a shower chair without safety belt secured, sustaining a head injury, and the incident was not reported to the New York State Department of Health.
F 0684: The facility failed to provide appropriate treatment and care for Resident #314 by not obtaining a psychiatry consult until 20 days after a gradual dose reduction of Seroquel and not adequately managing behavioral symptoms.
F 0689: The facility failed to ensure adequate supervision and assistance to prevent accidents for Resident #364, who required two-person assistance for bathing but was showered alone, resulting in a fall with a subdural hematoma.
F 0880: The facility failed to implement an infection prevention and control program by staff not wearing appropriate PPE when providing care to residents on contact and droplet precautions and family members not removing gowns when exiting resident rooms.
Report Facts
Deficiencies cited: 5
Fall risk score: 16
Seroquel dosage: 37.5
Seroquel dosage: 12.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Reconciled medications with Resident #314's family member and reviewed medications with Physician Assistant |
| LPN #4 | Licensed Practical Nurse, Unit Manager | Spoke with Resident #314's family member about behaviors; did not notify family of Seroquel dose reduction until 6/1/2021 |
| LPN #5 | Licensed Practical Nurse | Documented Resident #314 on gradual dose reduction day 1; did not notify family of medication change |
| PA #1 | Physician Assistant | Reviewed hospital medications; did not discuss gradual dose reduction with Resident #314's family |
| Medical Director | Medical Director | Reviewed Resident #314's medication regimen on 6/1/2021; not involved in initial dose reduction |
| CNA #5 | Certified Nursing Assistant | Provided shower to Resident #364 alone; did not secure safety belt; witnessed fall |
| RNS #4 | Registered Nurse Supervisor | Assessed Resident #364 after fall |
| LPN #1 | Licensed Practical Nurse | Failed to wear appropriate PPE and gloves when administering insulin to Resident #26 on contact and droplet precautions |
| CNA #1 | Certified Nursing Assistant | Failed to wear gown and goggles when providing care to Resident #68 on contact and droplet precautions |
| CNA #2 | Certified Nursing Assistant | Failed to wear gown and goggles when providing care to Resident #68 on contact and droplet precautions |
| LPN #2 | Licensed Practical Nurse | Observed family member wearing gown in hallway; did not intervene |
| NP #1 | Nurse Practitioner | Ordered hospital transfer for Resident #364 after fall with head injury |
| Director of Nursing Services | Director of Nursing Services | Investigated Resident #364 fall; confirmed safety belt use expectation; stated staff education on shower chair safety belts |
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