Westgate

In the surveyor’s words

From the most serious findings on record at Westgate, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jun 4, 2026

  Based on observation, interview, and record review, the facility failed to provide care to promote the prevention and healing of pressure ulcers when staff failed to assess, monitor, document, and notify the physician for at least 17 days of a newly acquired Stage 4 (full thickness tissue loss with exposed bone) pressure ulcer that developed on one resident's (Resident #1) sacrum (the triangular bone located above the tailbone) which resulted in the resident requiring prolonged antibiotic treatment for probable osteomyelitis (an infection and inflammation of the bone typically caused by bacteria or fungi) and when staff failed to complete a wound treatment per physician order, and timely assess, document and notify the physician of five newly acquired pressure ulcers for one resident… […]

• Actual harm, isolatedF689Sep 29, 2023

  Based on interview and record review, the facility failed to ensure all residents received adequate supervision to prevent possible accidents when staff failed to respond to an alarm when one resident (Resident #1) left the facility at night, was found by a neighboring facility's staff, and suffered a fall with injury, and when the facility staff failed to have a process in place, and ensure all staff were trained on the process, to routinely check wander prevention devices to ensure they worked correctly for two residents (Resident #1 and Resident #2). […]

• No harm, potential for more than minimal, patternF584Jun 7, 2024

  Based on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to maintain the cleanliness of the the bathrooms of six residents (Resident's #51, #89, #32, #36, #39 and #102). The facility census was 108. Review showed the facility did not provide a policy that related to cleaning and maintain the bathrooms in residents' rooms. Review of the facility's cleaning sheet titled, Housekeeping 3 (300 hall), undated, showed the following: -Five step procedure for rooms included pull trash/sanitize can/replace liner, horizontal surfaces, vertical surfaces, dust mop, and damp mop; -Seven step procedure for bathrooms included check/refill supplies, pull trash/sanitize can/replace liner, dust mop/sweep, clean sink… […]

• No harm, potential for more than minimal, patternF761Jun 7, 2024

  Based on observation, interview, and record review, the facility failed to ensure all medications were stored per standards of practice when staff walked away and out of view of an unlocked medication cart containing resident medications. The facility census was 108. Review of the facility policy titled Administering Medications, revised 12/12, showed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse 1. Observation on 06/05/24, beginning at 2:45 P.M., showed Certified Medication Technician (CMT) D prepared medications for multiple residents and placed the cups containing the medication in the top drawer of the medication cart. The CMT then walked away from the medication cart without locking the care. […]

• No harm, potential for more than minimal, patternF561Jul 21, 2022

  Based on interview and record review, the facility failed to provided showers as preferred for nine residents (Resident #5, #13, #16, #39, #41, #68, #69, #74, and #78). The facility census was 89. Record review of the facility's policy titled Resident Bathing, undated, showed the staff shall provide person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. 1. During the resident group meeting held on 7/18/22, at 1:55 P.M., showed the following: -There were eight residents who attended the meeting; -The residents all agreed that they did not receive showers/baths on a regular basis and did not get two showers a week; -Resident #74 said he/she went three weeks without a shower and was finally given one last Wednesday or Thursday. […]