Westgate Hills Rehab & Healthcare CTR

In the surveyor’s words

From the most serious findings on record at Westgate Hills Rehab & Healthcare CTR, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF803May 22, 2026

  Based on observation and interview, the facility failed to ensure resident menu tickets were followed. This was evident for 1 of 1 kitchen tray line observation during an annual survey.The findings include:1) On 05/20/2026 at 11:46 AM, an observation revealed the kitchen lunch tray line started.On 05/20/2026 at 11:48 PM, an observation of the dessert prepared for the lunch tray line was brownies.During the lunch tray line, the surveyor observed the following residents had meal tickets that indicated cake with icing, but received a brownie on their lunch tray:Resident #16, #2, #78, #34, #11, #44, #26, #95, #42, #66, #93, #109, #53, #103, #90, #19, #36, #108, #68, #52, #51, #58, #121, #30, #97, #54, #61, #35, #92, #79, #50, #67, #7, #86, #37, #110, #80, #41, #96, and #33.On 05/20/2026 at… […]

• No harm, potential for more than minimal, patternF842May 22, 2026

  Based on interview and record review, it was determined that the facility failed to have accurate and complete medical records. This was found to be evident for 1) 5 (#1, #7, #10, #63, and #85) of 10 residents reviewed for advanced directives, 2) 2 (Resident #42 and #74) out of 2 residents reviewed for smoking, 3) 1 (#25) out of 1 resident review for accurate medical diagnosis in the medical record, and 4) 1 (#88) resident reviewed for accurately documented treatment during the annual survey.The findings include: 1) On 05/18/2026 at 11:21 AM, review of Resident #1's medical record revealed a document titled, MQS: Social Services Assessment - V11, dated 1/9/2026 revealed under section A1. the resident did not have an advanced directive and under section A3. […]

• No harm, potential for more than minimal, patternF919Oct 9, 2025

  Based on the review of complaints, observations and interviews, it was determined that the facility failed to have a fully functioning call bell system. This was evidenced by the lack of an audible call bell system on the second floor and had the potential of affecting all residents.The findings include:Tracheostomy is a surgical procedure that creates an opening in the trachea (windpipe) and inserts a tube to help a person breatheOn 10/07/2025 at 9:30 AM A review of complaint #328740 was conducted. The review revealed an allegation that stated call bells were not answered in a timely manner.On 10/07/2025 at 9:47 AM The surveyor observed that the call bell light was on outside room [ROOM NUMBER], which was located next to the nurses' station. […]

• No harm, potential for more than minimal, patternF812Apr 3, 2025

  Based on observations and interviews it was determined that the facility staff failed to properly store food in accordance with professional standards for food service and safety. This was found evident in 1 of 3 kitchen observations and 1 out of 2 unit storage refrigerators during the survey. This has the potential to affect all residents. The findings include: On [DATE] at 8:15 AM, the surveyor made an initial tour of the kitchen. The observation of the kitchen refrigerator revealed two containers that were labeled cottage cheese. The first one was labeled with a received on date of [DATE] and a sell by date of [DATE]. The second container had a received on date of [DATE] and a sell by date of [DATE] date. Also noted was a small block of lunch meat. […]

• No harm, potential for more than minimal, patternF609Jan 16, 2025

  Based on review of facility reported incidents with documentation and interview, it was determined the facility failed to report 1) allegation of misappropriation of property, 2) an injury of unknown source and 3) allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 6 (#31, #42, #47, #34, #48, #50) of 50 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 1/7/25 at 11:30 AM facility reported incident MD00192632 was reviewed and revealed an allegation that on 5/22/23 at approximately 3:00 AM Resident #31 requested to speak with a nursing supervisor to report a geriatric nursing assistant (GNA) threatened the resident, yelled and pounded her first against in the… […]