Westridge Health Care Center

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

gabapentin, pramipexol, sertraline, and tizanidine medications. Resident G had an order for Xarelto 15 mg to be administered at 5:00 p.m. which was due to be administered prior to the 6:00 p.m. medications.

During an interview on 9/19/25 at 3:48 p.m. the Nurse Consultant indicated at no time should medications be handled with bare hands. She indicated she believed staff were able to pre-set medications for one medication pass. The facility policy had referenced pre-pour, which she believed indicated prepare in advance. During an interview on 9/19/25 at 2:32 p.m., the DON indicated she believed pre-pour meant prepare in the facility policy. 2. During an interview on 9/18/25 at 2:55 p.m., Resident D indicated LPN 4 had tried to give him the wrong medications on two separate occasions while he was in the dining room for dinner. She would set a cup of medications down in front of him and walk away. He got her attention when

she returned to give another resident their medication cup and told her the medications in his cup were not

the ones he takes in the evenings. She indicated to him that they were not his medications, and she would return with his medications. On another occasion his sister was present at the dining table when LPN 4 set his medication cup down for him to take. He told his sister that these were not his medications, and his sister went to find LPN 4 to get his correct medications. The clinical record for Resident D was reviewed on 9/18/25 at 10:48 a.m. Diagnoses included hemiplegia/hemiparesis following a stroke affecting his right side, chronic respiratory failure, major depressive disorder, and anxiety. A quarterly Minimum Data Set (MDS) assessment, dated 8/5/25, indicated the resident was cognitively intact, had no delusions or hallucinations, no behaviors, and no rejection of care. During an interview on 9/19/25 at 1:21 p.m., Resident D's sister indicated she had visited Resident D for dinner and was seated in the dining room. LPN 4 brought his medication in a little, clear cup and set them down in front of him and indicated, here's your medications [Resident D], and left the dining room. Resident D looked at the medications and told her they were not his.

She took the cup and went to locate LPN 4. She found her in the hallway and informed her the medications were not her brother's. LPN 4 replied that she had given him the wrong medications and took the cup. She later returned to the dining room and watched her Brother take his medications. She had reported this to

the Director of Nursing the following day and the DON replied [Resident D] must be confused about what medications he's taking. The DON had not given her the opportunity to tell her that the nurse had admitted to providing the wrong medications. During an interview on 9/18/25 at 3:33 p.m., LPN 4 indicated she recalled the incidents with the medication cups. She had caught her error prior to the resident taking the cup. There was another occasion when she set another resident's cup of medications down for him to take and immediately realized her error and picked it back up. At no time had Resident D said anything to her about them not being his medications. Both times she had caught her error. He had not even known they were the wrong pills. A current facility policy, revised 4/2017, titled, Medication Administration, provided by

the DON on 9/18/25 at 3:35 p.m., included the following: Purpose: To safely administer medications as per physicians' orders Preparation: .6. Never pre-pour medications .Infection Control: .3. Never touch medications with hands Guidelines for Medication Administration: .5. Medications are to be prepared just prior to administration. Never pre-pour medications for more than one medication pass 19. Always observe

the resident taking their medication(s). This citation relates to Intake 1396147.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Westridge Health Care Center

125 W Margaret Ave Terre Haute, IN 47802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation and interview, the facility failed to assure nursing staff were using proper hygiene and infection control when preparing to administer medications for 1 of 2 observations for medication pass.

Findings include:During a random observation on 9/18/25 at 3:32 p.m., LPN 4 was observed seated at the 100 hall nurses' station. The desk had multiple cards of medications and plastic medication cups, with initials marked on the outer surface. LPN 4 was dispensing pills from the medication cards into her bare hands and placing the pills in the medication cups. She dropped a pill onto the desk surface, picked it up with her bare hands, and placed it into the medication cup. She indicated she had not realized it was an issue after washing her hands. During an interview on 9/19/25 at 3:48 p.m. the Nurse Consultant indicated at no time should medications be handled with bare hands. A current facility policy, revised 4/2017, titled, Medication Administration, provided by the DON on 9/18/25 at 3:35 p.m., included the following: Purpose: To safely administer medications as per physicians' orders .Infection control: .3. Never touch medications with hands Guidelines for Medication Administration: 13. Never touch medications with your hands. This citation relates to Intake 1396147. 3.1-18(b)(1)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet