Westridge Health Care Center: Medication Hygiene Failure - IN
An inspector watched the entire sequence on September 18, 2025, at 3:32 in the afternoon.
The licensed practical nurse, identified in inspection records as LPN 4, was seated at the 100 hall nurses' station. The desk around her held multiple cards of medications and plastic medication cups, each marked with initials on the outside. She was working through the medication pass, popping pills from blister cards directly into her palm and transferring them into the cups. When one pill fell onto the desk surface, she picked it up the same way she had been handling all the others, with her bare hands, and it went into the cup.
When asked about it, she said she had not realized it was an issue after washing her hands.
The facility's own written policy said otherwise, and had said so for at least eight years. A medication administration policy, revised in April 2017 and provided by the Director of Nursing the same afternoon the observation was made, contained the instruction twice: "Never touch medications with hands." Once under infection control guidelines. Once under general medication administration guidelines. The same sentence, written out twice, as if whoever wrote the policy understood that once might not be enough.
The Nurse Consultant, interviewed the following day, was direct. At no time, she said, should medications be handled with bare hands.
The concern is not abstract. A nurse's hands, even recently washed, carry bacteria and other contaminants. A desk surface at a busy nurses' station carries more. A pill that travels from a blister card to a bare palm to a desk to that same palm to a medication cup has made contact with surfaces and skin that residents, many of them elderly and medically vulnerable, never agreed to. The infection control logic behind the policy is straightforward, which is part of what makes the gap between the written rule and what the inspector watched so difficult to explain.
Inspectors rated the violation as causing minimal harm or potential for actual harm, and noted it affected few residents. The observation covered one of two medication passes reviewed during the complaint inspection.
What the record does not explain is how a practice this basic, one covered explicitly in a policy the facility itself maintained and provided on request within minutes of the observation, went undetected long enough to show up during a complaint inspection. LPN 4's response, that she had not realized it was a problem after washing her hands, suggests the behavior was not new. People do not typically develop workarounds to policies they have never tried to follow.
Westridge Health Care Center is a nursing facility in Terre Haute. The inspection was conducted in response to a complaint, logged under intake number 1396147. The citation falls under Indiana state regulation 3.1-18(b)(1).
The pills that went into that medication cup on the afternoon of September 18 were administered to a resident. The inspection report does not say what happened after that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westridge Health Care Center from 2025-09-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 17, 2026 · Our methodology
WESTRIDGE HEALTH CARE CENTER in TERRE HAUTE, IN was cited for violations during a health inspection on September 19, 2025.
An inspector watched the entire sequence on September 18, 2025, at 3:32 in the afternoon.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.