Westridge Health Care: Medication Mix-Ups Dismissed - IN
That exchange is now part of a federal inspection record at Westridge Health Care Center, a 125-bed facility on West Margaret Avenue, following a complaint inspection completed September 19, 2025.
The resident at the center of the medication errors, identified in inspection records as Resident D, is cognitively intact. His diagnoses include hemiplegia and hemiparesis following a stroke affecting his right side, chronic respiratory failure, major depressive disorder, and anxiety. A quarterly assessment completed August 5, 2025 documented no confusion, no delusions, no behavioral issues.
The first incident happened in the dining room during dinner. LPN 4 set a small clear cup of medications on the table in front of Resident D and walked away. He looked at the pills and recognized they weren't his. When she came back to deliver medications to another resident nearby, he got her attention and told her. She acknowledged the error and said she'd return with the correct ones.
The second time, his sister was sitting with him at the dining table. LPN 4 set the cup down, said "here's your medications," and left the dining room. Resident D looked at the pills and told his sister they weren't his. She picked up the cup, went into the hallway, found LPN 4, and told her the medications weren't her brother's. The nurse replied that she had given him the wrong medications. She took the cup back and returned later to watch him take the correct ones.
The following day, Resident D's sister called the Director of Nursing to report what had happened. The DON's response, according to the sister's account to inspectors, was that Resident D must be confused about what medications he's taking. The DON did not give her the chance to explain that the nurse had already admitted to the error herself.
LPN 4 told inspectors a different version of both incidents. She said she had caught her own errors before Resident D ever saw the cups. On one occasion, she said, she set down the wrong cup and immediately picked it back up. On the other, she said she caught it before he'd said anything. He had not even known they were the wrong pills, she told inspectors. At no time, she said, had he told her the medications weren't his.
That account contradicts what Resident D told inspectors, what his sister told inspectors, and what the sister said the nurse told her in the hallway.
The inspection also flagged a separate medication handling problem. Inspectors observed a nurse preparing medications with bare hands, touching pills directly before placing them in cups. A second nurse was observed pre-setting multiple residents' medications in advance of the medication pass, lining cups up on the cart before beginning rounds.
The facility's own policy, revised in April 2017, states medications should never be touched with hands and should never be pre-poured for more than one medication pass. Medications are to be prepared just prior to administration.
The Nurse Consultant told inspectors that at no time should medications be handled with bare hands, and that she believed pre-setting medications for one pass in advance was permissible. The Director of Nursing said she also believed "pre-pour" in the policy meant preparation in advance. The policy does not say that.
One of the residents whose medications were being pre-set had an active order for Xarelto, a blood thinner, to be administered at 5:00 p.m., before the 6:00 p.m. medication pass. Pre-setting that medication with others meant its scheduled administration time was at risk of being missed or delayed.
Inspectors cited the facility under federal tag F0726, which covers nurse competency, and assigned a harm level of minimal harm or potential for actual harm.
Resident D's sister watched her brother take his correct medications before she left that evening. What she didn't know, until she called the next day, was how the facility would characterize what he had seen with his own eyes.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
WESTRIDGE HEALTH CARE CENTER in TERRE HAUTE, IN was cited for violations during a health inspection on September 19, 2025.
The resident at the center of the medication errors, identified in inspection records as Resident D, is cognitively intact.
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.