Westgate Gardens Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 4, 2025

  Based on interview and record review, the facility failed to ensure the staff used the Hoyer lift (mechanical device designed to assist individuals with limited mobility in safely transferring from one place to another) properly when the legs (base) of the Hoyer lift were not open during a transfer for one of three sampled residents (Resident 1). This failure resulted in the Hoyer lift tilting over causing Resident 1 to fall to the floor, sustaining a mild displaced (bone fragments are no longer together) distal (away from the point of attachment) coccygeal (tailbone) segment (completely detached from surrounding bone) fracture (break in a bone).Findings:During a review of Resident 1's admission Record (AR) dated 6/10/25, the AR indicated, Resident 1 was admitted to the facility on [DATE]… […]

• Actual harm, isolatedF689May 24, 2021

  Based on observation, interview, and record review, the facility failed to ensure one of four shower beds (a medical device used to transport and shower people who are unable to stand or sit in a chair) was in a safe and operable manner for one of nine sampled residents (Resident 1). This failure resulted with one shower bed having a missing part which resulted in the shower bed collapsing while in use, Resident 1 falling from the shower bed, hitting her head on the shower wall, and the potential for significant injury. […]

• No harm, potential for more than minimal, widespreadF812Aug 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure expired foods were not available to be served when there was molded Hawaiian rolls and expired rice vinegar in the dry food storage area. This had the potential to be served to the residents and cause food borne illness. Findings: During a concurrent observation and interview, on [DATE], at 8:28 a.m., with Director of Dietary Services (DDS), in the kitchen dry storage room, the bread storage area contained two packages of Hawaiian rolls. Each package contained 12 Hawaiian rolls for a total of 24 Hawaiian rolls. Out of 24 Hawaiian rolls approximately 18 had mold on them. […]

• No harm, potential for more than minimal, patternF578Feb 24, 2025

  Based on interview and record review, the facility failed to ensure Advance Directives (AD-a legal document indicating resident preference on end-of-life treatment decisions) were offered and completed for two of 32 sampled residents (Resident 19 and Resident 103). This failure had the potential for residents' healthcare wishes to not be honored. Findings: During a concurrent interview and record review on 2/20/25 at 9:25 a.m. with Nursing Consultant (NC), NC was unable to provide documentation of an AD for Resident 19. NC stated there is no AD on file or no documentation of AD being offered or discussed with Resident 19 or Resident 19's responsible party. 51320 During a concurrent interview and record review on 2/24/25 at 11:28 a.m. […]

• No harm, potential for more than minimal, patternF847Feb 24, 2025

  Based on interview and record review, the facility failed to ensure its arbitration agreement explicitly indicated that the resident or his or her representative had the right to rescind the agreement within 30 calendar days of signing the arbitration agreement. This failure had the potential for 92 of 138 residents who signed arbitration agreements not to understand their right to rescind the arbitration agreement within 30 days. Findings: During a concurrent interview and record review on 2/24/25 at 9:30 a.m. with the Admissions Director (AD), the facility's list of current residents who signed arbitration agreements was reviewed. A review of the list of current residents who signed arbitration agreements indicated 92 of 138 residents had signed it. […]