Inspection Reports for Westridge Health Care Center
125 W Margaret Ave, Terre Haute, IN 47802, IN, 47802
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 6, 2025, found no deficiencies related to complaint investigations. Earlier inspections showed a pattern of deficiencies primarily involving care planning, medication management, infection control, and life safety issues such as sprinkler system maintenance and corridor door compliance. Complaint investigations were mostly unsubstantiated, with one substantiated deficiency in June 2024 related to failure to update care plans with post-fall interventions. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to be improving over time, with recent inspections showing fewer issues compared to prior years.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
210% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 19, 2025
Visit Reason
The inspection was conducted due to a complaint regarding medication administration practices and infection control at Westridge Health Care Center.
Complaint Details
The complaint involved unsafe medication administration practices by LPN 4, including giving wrong medications to Resident D on two occasions and handling medications with bare hands, contrary to facility policy. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure safe and accurate medication administration for 4 residents, with observed errors in medication preparation and handling. Additionally, nursing staff were found to be using improper hygiene by handling medications with bare hands, violating facility policy.
Deficiencies (2)
Failure to ensure nurses and nurse aides have appropriate competencies to care for residents, specifically related to safe and accurate medication administration.
Failure to provide and implement an infection prevention and control program, evidenced by staff handling medications with bare hands.
Report Facts
Residents reviewed for pharmaceutical services: 4
Medication cups observed: 9
Date of medication observation: Sep 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Observed improperly handling medications and involved in medication errors | |
| Director of Nursing (DON) | Present during observation and interviewed regarding medication preparation policy | |
| Nurse Consultant | Present during observation and interviewed regarding medication handling practices |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 42
Deficiencies: 0
Date: Jun 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00459205 and IN00460316.
Complaint Details
Complaint IN00459205 - No deficiencies related to the allegations are cited. Complaint IN00460316 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaints IN00459205 and IN00460316 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 5
Medicaid census: 33
Other payor census: 4
Inspection Report
Re-Inspection
Census: 45
Capacity: 66
Deficiencies: 0
Date: May 14, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/01/25 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Westridge Health Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for a detached laundry and a detached storage shed.
Report Facts
Facility capacity: 66
Census: 45
Inspection Report
Life Safety
Census: 45
Capacity: 66
Deficiencies: 2
Date: Apr 1, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey identified deficiencies related to sprinkler system installation and liquid oxygen equipment storage, affecting resident safety and fire protection compliance.
Deficiencies (2)
Failed to maintain ceiling construction in accordance with NFPA 13; escutcheon plates did not completely cover holes around sprinklers in two locations exposing attic space.
Failed to protect 5 resident rooms from use of liquid oxygen containers stored in patient bed locations or care rooms not separated by fire barriers with minimum 1-hour fire resistance rating; corridor doors were not self-closing or automatic closing and lacked fire resistance rating labels.
Report Facts
Certified beds: 66
Census: 45
Residents potentially affected by sprinkler deficiency: 15
Resident rooms affected by liquid oxygen deficiency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Bloesing | Administrator | Named in relation to exit conference and survey report |
| Maintenance Director | Interviewed regarding sprinkler and liquid oxygen deficiencies; name not provided |
Inspection Report
Annual Inspection
Census: 41
Capacity: 41
Deficiencies: 5
Date: Mar 20, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00455208.
Complaint Details
Complaint IN00455208 was investigated during this visit; no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in several areas including failure to provide showers/bed baths as preferred for some residents, failure to dispose of expired medications, failure to label and date refrigerated and frozen food items, failure to document timely hospital transfer notifications, and improper handling of glucometers during blood glucose monitoring.
Deficiencies (5)
Failed to ensure residents were provided showers/bed baths as preferred for 2 of 3 reviewed residents (Residents 41 and 40).
Failed to ensure expired medications were disposed of for 1 of 2 medication carts and 1 of 2 medication storage rooms reviewed (Residents 36 and 26).
Failed to label and date refrigerated and frozen food items and prevent possible contamination from water dripping onto food items in the refrigerator.
Failed to ensure documentation of facility contact with the hospital prior to a resident transfer was completed timely for 1 of 4 residents reviewed for hospitalization (Resident 31).
Failed to ensure proper handling of the glucometer during blood glucose monitoring for 2 of 2 observations (Residents 42 and 35).
Report Facts
Survey dates: 5
Census: 41
Total capacity: 41
Medicare residents: 5
Medicaid residents: 34
Other payor residents: 2
Scheduled showers for Resident 40: 30
Showers received by Resident 40: 17
Expired insulin vials: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Bloesing | Administrator | Signed the report and provided statements during the survey |
| QMA 7 | Qualified Medication Aide | Interviewed regarding expired insulin and glucometer handling |
| QMA 8 | Qualified Medication Aide | Interviewed regarding expired insulin pen |
| Certified Nurse Aide 6 | CNA | Interviewed regarding resident bed baths |
| Certified Nurse Aide 10 | CNA | Interviewed regarding shower schedules and refusals |
| Certified Nurse Aide 9 | CNA | Interviewed regarding shower schedules and refusals |
| Certified Nurse Aide 3 | CNA | Interviewed regarding staffing and shower administration |
| Dietary Manager | Interviewed regarding kitchen observations and food storage | |
| Regional Nurse Consultant | Provided facility policies and documentation | |
| Corporate Nurse Consultant | Provided facility policies and documentation |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
Paper compliance review to the Recertification and Licensure Survey completed on March 20, 2025.
Findings
Westridge Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and Licensure Survey.
Inspection Report
Routine
Deficiencies: 5
Date: Mar 20, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, food safety, medical record documentation, and infection control at Westridge Health Care Center.
Findings
The facility was found deficient in multiple areas including failure to provide residents with preferred showers/bed baths as scheduled, improper disposal of expired medications, inadequate labeling and storage of food items, incomplete documentation of hospital transfer notifications, and improper handling of glucometers during blood glucose monitoring.
Deficiencies (5)
Failed to ensure residents were provided showers/bed baths as preferred for 2 of 3 reviewed residents (Residents 41 and 40).
Failed to ensure expired medications were disposed of for 1 of 2 medication carts and 1 of 2 medication storage rooms reviewed (Residents 36 and 26).
Failed to label and date refrigerated and frozen food items and prevent possible contamination from water dripping onto food items in the refrigerator.
Failed to ensure documentation of facility contact with hospital prior to resident transfer was completed timely for 1 of 4 residents reviewed for hospitalization (Resident 31).
Failed to ensure proper handling of glucometers during blood glucose monitoring for 2 of 2 observations (Residents 42 and 35).
Report Facts
Scheduled bed baths missed: 4
Scheduled showers: 30
Showers received: 17
Expired insulin vials: 2
Expired insulin pen: 1
Dates on food items: 2
Undated frozen food items: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse's Aide 6 | CNA | Interviewed regarding Resident 41's bed bath schedule and staffing challenges. |
| Certified Nurse's Aide 10 | CNA | Interviewed regarding shower schedules and documentation for Resident 40. |
| Certified Nurse's Aide 9 | CNA | Interviewed about shower refusals and documentation procedures. |
| Director of Nursing | DON | Provided information on shower refusals, documentation, and shower sheet usage. |
| Qualified Medication Aide 7 | QMA | Interviewed about expired insulin vials and glucometer cleaning procedures. |
| Qualified Medication Aide 8 | QMA | Interviewed about expired insulin pen found in medication storage. |
| Employee 11 | Observed and interviewed regarding kitchen refrigerator and freezer food labeling. | |
| Employee 12 | Observed kitchen refrigerator water contamination. | |
| Dietary Manager | Interviewed about water contamination in refrigerator. | |
| Cooperate Nurse Consultant | Provided policy documents and clarification on documentation and infection control. | |
| Administrator | Interviewed regarding bed bath documentation, hospital transfer documentation, and policies. | |
| Qualified Medication Aide 10 | QMA | Interviewed about proper glucometer handling procedures. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 0
Date: Mar 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00454697 and IN00454416.
Complaint Details
Complaint IN00454697 - No deficiencies related to the allegations are cited. Complaint IN00454416 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in Complaints IN00454697 and IN00454416 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 5
Medicaid census: 36
Other payor census: 2
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Date: Feb 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451313.
Complaint Details
Complaint IN00451313 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 4
Medicaid census: 37
Other payor census: 3
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442069.
Complaint Details
Complaint IN00442069 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00442069 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 44
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 35
Census Payor Type Other: 2
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 22, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00435269 completed on June 6, 2024.
Complaint Details
Investigation of Complaint IN00435269 was completed; facility found in compliance.
Findings
Westridge Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Investigation of Complaint IN00435269.
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Date: Jun 28, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437107.
Complaint Details
Investigation of Complaint IN00437107 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00437107 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 44
Total Capacity: 44
Medicare Residents: 1
Medicaid Residents: 40
Other Residents: 3
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 1
Date: Jun 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435269 regarding federal and state deficiencies related to allegations of failure to update care plans with post-fall interventions.
Complaint Details
Complaint IN00435269 was substantiated with federal and state deficiencies cited at F657 related to failure to update care plans with post-fall interventions.
Findings
The facility failed to update care plans with post-fall interventions for 4 of 6 residents reviewed for falls. Multiple residents' medical records lacked documentation of post-fall immediate interventions despite documented falls and injuries.
Deficiencies (1)
Failure to update care plans with post-fall interventions for residents B, C, H, and K.
Report Facts
Census: 44
SNF/NF Census: 3
SNF Census: 3
NF Census: 38
Medicare Census: 3
Medicaid Census: 38
Other Payor Census: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Gustus | MSN, RN Consultant | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to update care plans with post-fall interventions for multiple residents who experienced falls.
Complaint Details
This citation relates to Complaint IN00435269.
Findings
The facility failed to update care plans with immediate post-fall interventions for 4 of 6 residents reviewed for falls. Documentation and care plans lacked evidence of interventions addressing fall risks and post-fall care, despite multiple falls and injuries requiring emergency care.
Deficiencies (1)
Failed to update care plans with post fall interventions for 4 of 6 residents reviewed for falls (Residents B, C, H, and K).
Report Facts
Residents affected: 4
Falls documented: 3
Falls dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Indicated Resident H had fallen in the last 60 days but record lacked documentation of a fall | |
| Qualified Medication Aide (QMA) 4 | Indicated care plans were on paper chart and was unsure who updated them | |
| Regional Nurse Consultant | Indicated CNAs and nurses received report and discussed falls and interventions; provided facility policy document |
Inspection Report
Re-Inspection
Census: 44
Capacity: 66
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Westridge Health Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for detached laundry and storage areas.
Report Facts
Facility capacity: 66
Census: 44
Inspection Report
Life Safety
Census: 45
Capacity: 66
Deficiencies: 1
Date: Apr 5, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively on 04/05/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, during the Life Safety Code survey, the facility was found not in compliance due to 3 of over 40 corridor doors failing to close and latch properly, potentially affecting 6 residents.
Deficiencies (1)
Failed to ensure 3 of over 40 corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke, affecting 6 residents.
Report Facts
Certified beds: 66
Census: 45
Deficient corridor doors: 3
Residents potentially affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Bloesing | administrator | Signed the report and was present at exit conference |
| Maintenance Director | Confirmed the corridor doors did not latch properly during observation and interview |
Inspection Report
Renewal
Census: 45
Capacity: 45
Deficiencies: 5
Date: Mar 1, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 26 to March 1, 2024.
Findings
The facility was found deficient in several areas including call light accessibility for residents, qualified staff performing pressure ulcer treatments, provision of range of motion treatments, dish machine sanitizing temperature, and proper linen handling procedures.
Deficiencies (5)
Failed to ensure a call light device was in reach for 1 of 16 residents reviewed (Resident 34).
Failed to ensure pressure ulcer treatments were completed by qualified staff and proper standards followed for 1 of 1 residents reviewed for pressure ulcer care (Resident 29).
Failed to provide treatment to prevent further decrease in range of motion for 1 of 2 residents reviewed for range of motion (Resident 32).
Failed to ensure the wash temperature of the chemical sanitizing dish machine met required temperature during kitchen observations.
Failed to ensure clean linen was carried away from the body and soiled linen was in a container while transporting in the hallway during 5 of 5 random observations for linen handling.
Report Facts
Census: 45
Total Capacity: 45
Dish machine wash temperature: 80
Dish machine temperature logs: 100
Pressure ulcer dressing changes documented by QMA 6: 19
Pressure ulcer dressing changes documented by QMA 11: 5
Pressure ulcer dressing changes documented by QMA 16: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Bloesing | Administrator | Signed the report |
| QMA 6 | Qualified Medication Aide | Documented pressure ulcer dressing changes and interviewed regarding scope of practice |
| QMA 11 | Qualified Medication Aide | Documented pressure ulcer dressing changes and interviewed regarding scope of practice |
| QMA 16 | Qualified Medication Aide | Documented pressure ulcer dressing changes and interviewed regarding scope of practice |
| Director of Nursing | Director of Nursing | Interviewed regarding call light placement and wound care practices |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided facility policies and interviewed regarding wound care and call light policies |
| Certified Occupational Therapy Assistant | COTA | Interviewed regarding evaluation of resident with contracture |
| Certified Nursing Assistant 21 | CNA | Observed carrying linens against body |
| Certified Nursing Assistant 20 | CNA | Observed carrying linens against body |
| Employee 3 | Observed carrying soiled linens against body |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 1, 2024
Visit Reason
Paper compliance review to the Recertification and Licensure Survey completed on March 1, 2024.
Findings
Westridge Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and Licensure Survey.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 1, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, facility operations, and safety standards at Westridge Health Care Center.
Findings
The facility was found deficient in multiple areas including failure to ensure call light devices were within reach of residents, improper pressure ulcer treatment by unqualified staff, lack of treatment to prevent further decrease in range of motion, inadequate dish machine wash temperatures, and improper linen handling practices.
Deficiencies (5)
Failed to ensure a call light device was in reach for 1 of 16 residents reviewed for call light placement (Resident 34).
Failed to ensure pressure ulcer treatments were completed by qualified staff and staff followed proper standards of practice for 1 of 1 residents reviewed for pressure ulcer care (Resident 29).
Failed to provide treatment to prevent further decrease in range of motion for 1 of 2 sampled residents reviewed for range of motion (Resident 32).
Failed to ensure the wash temperature of the chemical sanitizing dish machine met the required temperature during kitchen observations.
Failed to ensure clean linen was carried away from the body and soiled linen was in a container while transporting in the hallway during 5 of 5 random observations for linen handling.
Report Facts
Residents reviewed for call light placement: 16
Residents reviewed for pressure ulcer care: 1
Residents reviewed for range of motion: 2
Dish machine wash temperature: 80
Dish machine temperature logs: 100
Pressure ulcer wound measurements: 3
Pressure ulcer wound measurements: 1.5
Pressure ulcer wound measurements: 1.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding call light placement, pressure ulcer dressing changes, and range of motion treatments |
| Regional Nurse Consultant | Regional Nurse Consultant (RNS) | Provided facility policies and interviewed regarding pressure ulcer care and linen handling |
| Qualified Medication Aide 6 | Qualified Medication Aide (QMA) | Interviewed and documented pressure ulcer dressing changes beyond scope of practice |
| Qualified Medication Aide 11 | Qualified Medication Aide (QMA) | Interviewed regarding scope of practice for dressing changes |
| Qualified Medication Aide 16 | Qualified Medication Aide (QMA) | Interviewed regarding scope of practice for dressing changes |
| Certified Occupational Therapy Assistant | Certified Occupational Therapy Assistant (COTA) | Interviewed regarding evaluation and treatment orders for contracture |
| Certified Nurse Aide 13 | Certified Nurse Aide (CNA) | Interviewed regarding anti-contracture device use |
| Dietary Manager | Dietary Manager | Interviewed regarding dish machine temperatures and provided temperature logs |
| Certified Nursing Assistant 21 | Certified Nursing Assistant (CNA) | Observed carrying linens improperly and interviewed about linen handling |
| Certified Nursing Assistant 20 | Certified Nursing Assistant (CNA) | Observed carrying linens improperly |
| Certified Nursing Assistant 22 | Certified Nursing Assistant (CNA) | Interviewed regarding proper linen handling |
| Employee 3 | Observed carrying soiled linens improperly | |
| Employee 8 | Interviewed regarding linen handling policies |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Date: Oct 24, 2023
Visit Reason
This visit was for the investigation of complaints IN00419646 and IN00420382.
Complaint Details
Complaint IN00419646 - No deficiencies related to the allegations are cited. Complaint IN00420382 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00419646 and IN00420382 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 46
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 42
Census Payor Type - Other: 1
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Date: Aug 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412572.
Complaint Details
Complaint IN00412572 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00412572 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 3
Medicaid census: 40
Other payor census: 1
Inspection Report
Complaint Investigation
Census: 45
Capacity: 45
Deficiencies: 0
Date: Jun 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408801.
Complaint Details
Complaint IN00408801 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 45
Total Capacity: 45
Medicare Residents: 1
Medicaid Residents: 42
Other Payor Residents: 2
Inspection Report
Follow-Up
Census: 46
Capacity: 66
Deficiencies: 0
Date: Jun 13, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 05/08/23.
Findings
At this PSR survey, Westridge Health Care Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for a detached laundry and a maintenance storage area, and had a fire alarm system with smoke detection in required areas.
Report Facts
Certified beds: 66
Census: 46
Inspection Report
Life Safety
Census: 45
Capacity: 66
Deficiencies: 6
Date: May 8, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with emergency preparedness requirements and life safety codes.
Findings
The facility was found not in compliance with emergency preparedness testing requirements, emergency power system maintenance and testing, and life safety code corridor door latching. Deficiencies included failure to conduct required emergency preparedness exercises twice yearly, incomplete generator testing documentation and insufficient generator run time under load, lack of documented cool down time after generator testing, missing transfer time documentation, corridor doors that did not latch properly, and improper use of power strips for high current equipment.
Deficiencies (6)
Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills.
Failed to implement emergency power system inspection, testing, and maintenance requirements; generator run time under load was 15 minutes instead of required 30 minutes.
Failed to allow 5 minute cool down period after generator load test.
Failed to maintain complete documentation for monthly generator testing including load percentages and transfer time to emergency power.
Two corridor doors (Rooms 208 and 316) did not close and latch properly to resist passage of smoke.
Power strip used to power a dorm style refrigerator and coffee maker, which is not permitted as a substitute for fixed wiring for high current draw equipment.
Report Facts
Certified beds: 66
Census: 45
Generator monthly run time: 15
Required generator run time: 30
Generator cool down time: 5
Number of corridor doors not latching: 2
Number of power strips misused: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Bloesing | administrator | Signed report and participated in exit conference |
| Maintenance Director | Interviewed regarding emergency preparedness exercises, generator testing, and door latching deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 17, 2023
Visit Reason
Paper compliance review to the Recertification and Licensure Survey.
Findings
Westridge Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and Licensure Survey.
Inspection Report
Annual Inspection
Census: 47
Capacity: 47
Deficiencies: 9
Date: Apr 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from April 11 to April 17, 2023.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive person-centered care plans, failure to ensure resident and representative participation in care plan meetings, failure to update care plans timely, improper handling of urinary catheters, improper storage of nebulizer equipment, improper cleaning of glucometers, medication labeling errors, failure to document medication administration properly, and improper food handling during dining services.
Deficiencies (9)
Failed to develop and implement a comprehensive person-centered care plan for 1 of 1 resident reviewed for edema (Resident 26).
Failed to ensure resident and representative attendance and review of care plan meetings for 1 of 16 residents (Resident 21) and failed to update care plans for 2 of 16 residents (Residents 17 and 20).
Failed to ensure indwelling urinary catheter drainage bag was kept from contact with the floor for 1 of 2 residents reviewed (Resident 34).
Failed to ensure nebulizer tubing and mouthpiece were dated, timed, and signed for 1 of 1 resident observed (Resident 20).
Failed to ensure staff competency in cleaning glucometer after use for 1 of 1 observation (Resident 46).
Failed to ensure monitoring of anticoagulant medication for 1 of 5 residents reviewed (Resident 12).
Failed to ensure medications and supplements were properly labeled and updated with physician's order changes for 2 of 2 residents observed (Residents 46 and 47).
Failed to ensure proper documentation of psychotropic medication administration for 1 of 5 residents reviewed (Resident 24).
Failed to ensure proper handling of food during dining observation; staff touched food with bare hands.
Report Facts
Census: 47
Total Capacity: 47
Medicare Census: 4
Medicaid Census: 43
Survey Dates: 5
Deficiency Count: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Gustus | MSN, RN Consultant | Signed the report and plan of correction |
Inspection Report
Routine
Deficiencies: 9
Date: Apr 11, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, care planning, infection control, and facility operations at Westridge Health Care Center.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans, failure to ensure resident and representative participation in care plan meetings, inadequate catheter care, improper handling and labeling of medications and supplements, failure to properly clean respiratory equipment, inadequate staff competency in glucometer cleaning, failure to monitor anticoagulant medication side effects, improper food handling, and incomplete documentation of psychotropic medication administration.
Deficiencies (9)
Failed to develop and implement a comprehensive person-centered care plan for a resident with edema.
Failed to ensure resident and representative attendance and review of care plan meetings for multiple residents.
Failed to ensure indwelling urinary catheter drainage bag was kept from contact with the floor.
Failed to ensure nebulizer tubing and mouthpiece were dated, timed, and signed for respiratory equipment.
Failed to ensure staff competency in cleaning the glucometer after blood glucose monitoring.
Failed to ensure monitoring of side effects of anticoagulant medication for a resident.
Failed to ensure medications were labeled with updated physician's orders and supplements labeled with resident's name and room number.
Failed to ensure proper handling of food during dining observation; staff touched food with bare hands.
Failed to ensure documentation of psychotropic medications administered for a resident.
Report Facts
Residents reviewed for care plan meetings: 16
Residents reviewed for unnecessary medications: 5
Units of Humalog insulin: 15
Supplement dose: 60
Medication doses missed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Qualified Medication Aide 12 | QMA | Observed performing blood glucose monitoring and improperly cleaning glucometer |
| Director of Nursing | DON | Interviewed regarding care plan updates, catheter care, and medication administration issues |
| Corporate Nurse Consultant | Provided policies and interviews related to care plan, medication administration, and infection control | |
| Certified Nursing Assistant 8 | CNA | Observed touching resident food with bare hands during meal service |
| Qualified Medication Aide 14 | QMA | Observed administering supplement medication without proper labeling |
| Licensed Practical Nurse 3 | LPN | Observed administering insulin medication with outdated label |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Date: Mar 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399896.
Complaint Details
Complaint IN00399896 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations regarding the complaint investigation.
Report Facts
Census Payor Type SNF/NF: 45
Census Bed Type Medicare: 4
Census Bed Type Medicaid: 41
Total Census: 45
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 30, 2022
Visit Reason
Paper compliance review related to an unrelated deficiency cited during the Investigation of Complaint IN00391772 completed on October 7, 2022.
Complaint Details
Investigation of Complaint IN00391772 completed on October 7, 2022; unrelated deficiency cited.
Findings
Westridge Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the unrelated deficiency cited during the complaint investigation.
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 1
Date: Oct 6, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391772, which was found to be unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00391772 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The facility failed to ensure that a resident (Resident C) with repetitive skin picking related to anxiety had a developed and implemented person-centered plan of care with goals and interventions to reduce or prevent skin picking. Multiple open skin lesions were observed, and care plans lacked documentation of behavioral health treatment goals and interventions.
Deficiencies (1)
Failure to develop and implement a person-centered plan of care with goals and interventions for a resident with repetitive skin picking related to anxiety.
Report Facts
Census: 46
Total Capacity: 46
Residents reviewed weekly for monitoring: 5
Books ordered: 4
Skin areas: 30
Sertraline dosage: 50
Parenteral feeding rate: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Bloesing | HFA | Signed plan of correction letter |
| Lisa Gustus | MSN, RN Consultant | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Employee 1 | Provided direct care to Resident C and interviewed regarding skin picking behavior and care | |
| Employee 2 | Provided nursing care to Resident C and interviewed regarding skin care and prevention efforts |
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