Westgate Hills Rehabilitation and Nursing CTR

In the surveyor’s words

From the most serious findings on record at Westgate Hills Rehabilitation and Nursing CTR, in the surveyor’s own words.

• Immediate jeopardy, patternF880Dec 14, 2023

  Based on observations, facility policy and clinical record review, and interview with staff, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases which resulted in an Immediate Jeopardy for 60 residents on the second floor nursing unit. Findings include: Review of facility policy titled COVID-19 Prevention, Response and Reporting with a revision date of December 7, 2023, revealed It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. […]

• Actual harm, isolatedF689Feb 17, 2023

  Based on observation, clinical record reviews, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance resulting in harm of lacerations to face and dental injury for one of the 26 residents reviewed (Resident 56). Findings include: Review of Resident 56's diagnosis list revealed Cerebrovascular Accident (CVA-damage to the brain from interruption of its blood supply), Epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), muscle wasting, and atrophy (thinning or loss of muscle tissue). […]

• No harm, potential for more than minimal, widespreadF812Jan 14, 2026

  Based on observations and staff interviews, it was determined that the facility failed to properly store food and maintain sanitary conditions and failed to properly label and date food products in the Main Kitchen which created the potential for cross contaminationFindings include: During an observation of the main kitchen on January 11, 2025, at 9:10 a.m. the following was observed: - Dry Storage: three packets of crackers on the floor, one maple syrup container on the floor, one used rubber glove on the floor, one open bag of pasta which also lacked proper dating and labeling, and one box containing 24 Glucerna Shakes on the floor -Walk in freezer- one open bag of chicken patties that was not sealed and missing appropriate date and label -Walk-in refrigerator- two open bags of bread… […]

• No harm, potential for more than minimal, widespreadF812Feb 17, 2023

  Based on facility policy and procedure review, facility documentation review, observations and staff interview it was determined the facility failed to store and prepare food in a safe manner in the main kitchen. Findings Include: Review of facility policy and procedure titled Food Temperatures, undated, revealed all cold food items must be stored and served at a temperature of 41 degrees Fahrenheit or below. Observation of the three reach-in refrigerators in the main kitchen on February 14, 2023 at 9:30 a.m. revealed all three reading of the external electronic thermometer and of the internal temperature gauge were reading above 41 degrees Fahrenheit. Observation of the three reach-in refrigerators in the main kitchen on February 17, 2023 at 9:15 a.m. […]

• No harm, potential for more than minimal, patternF835Dec 14, 2023

  Based on a review of job descriptions it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) did not effectively manage the facility to ensure proper infection prevention procedures were followed to protect residents from the spread of COVID-19 in the facility. Findings include: Review of the job description for the Nursing Home Administrator revealed the primary purpose of the job position is to direct day-to-day functions of the Facility in accordance with current federal, state, and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. […]