West Gables Health Care Center

In the surveyor’s words

From the most serious findings on record at West Gables Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Apr 9, 2021

  Based on observation, interviews and record review, the facility's staff failed to ensure infection control prevention measures and policies were implemented resulting in immediate jeopardy, as evidenced by 1) Failure to appropriately disinfect the multiple patient use glucometer, during observation of routine blood glucose testing Staff failed to properly disinfect the multi patient glucose monitoring device resulting in the likelihood of cross contamination and infection of a blood-borne pathogen and /or virus for 7 out of 18 residents observed (Residents #8, #12, #21, #28, #29, #30, and #45) that required blood glucose checks. 2) Facility Staff failed to dispose of sharps appropriately. […]

• No harm, potential for more than minimal, widespreadF812Dec 15, 2022

  Based on observation, interviews, and record review it was determined that the dish machine wash temperature did not reach the minimum manufacturer's recommended wash temperature as posted on the dish machine's face plate. Findings included: At 9:30 AM on 12/12/2022, a diet aide was observed running racks of dirty dishes through the dish machine. The wash and rinse temperature gauges were observed to read 150 degrees Fahrenheit (F) for the wash cycle and 180 degrees F for the rinse cycle. Observation of the manufacturer's face plate posted on the dish machine indicated the required temperature for the wash cycle should be at a minimum of 160 degrees F and the rinse cycle temperature should be at a minimum of 180 degrees F. […]

• No harm, potential for more than minimal, patternF808Dec 15, 2022

  Based on observation of residents at meals, interview with facility staff, and review of residents' diet orders as ordered by the Physician, the facility failed to ensure 15 residents ( Resident #1, Resident #3, Resident #6, Resident #7, Resident #18, # Resident 20, Resident #24, Resident #28, Resident #50, Resident #53, Resident #100, Resident #103, Resident #104, Resident #105, Resident #251) of 47 residents who were receiving nourishment by mouth, were receiving the correct Physician ordered diets. Observations of Resident #100 and Resident # 3 while at lunch were made to confirm the Physician ordered diet had not been served. Findings included: 1) Resident #100 was admitted to the facility on [DATE] with multiple diagnoses including End Stage Renal Disease (ESRD). […]

• No harm, potential for more than minimal, patternF919Dec 15, 2022

  Based on observations, staff interview and facility record review, the facility failed to ensure call lights were maintained and working effectively in three of thirty-three resident rooms, on three of three halls (wing A, wing B, and wing D). It was determined when pressing the pneumatic plastic bulbs, the call system did not activate. Findings included: 1. On 12/12/2022 at 10:28 AM the A wing was toured. Upon entering resident room [ROOM NUMBER] at 10:50 AM., both bed (a) and bed (b) call lights were tested for working maintenance. room [ROOM NUMBER] bed (a) was observed with a pneumatic bulb button. Upon pressing/squeezing the pneumatic bulb, it was determined the system did not trigger. Further observations revealed the light out in the hallway above the room door did not illuminate. […]

• No harm, potential for more than minimal, isolatedF689Dec 22, 2025

  Based on observation and interviews and record review, the facility failed to ensure that emergency bathroom call-light systems were properly installed, maintained, and accessible to residents to prevent accidents and ensure timely assistance for three rooms (Wing A (North) room [ROOM NUMBER] and 428, and Wing D (East), room [ROOM NUMBER]) out of sixty rooms on the facility's 4th floor. As evidenced by missing toilet-side emergency call-light cord in room [ROOM NUMBER] and missing shower call-light cords in rooms [ROOM NUMBERS]. This deficient practice significantly increased the risk of potential accidents and injuries. Fifty-four residents resided in the facility at the time of the survey. The findings include. […]