Westgate Nursing & Rehabilitation Community

In the surveyor’s words

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

• Actual harm, isolatedF686Sep 11, 2024

  Based on observation, interview and record review, the facility failed to implement measures to prevent additional pressure wound and/or prevent the development and worsening of pressure injuries for two Residents (R108 & R7) of five reviewed, resulting in harm for R108 with the development of a stage III pressure wound which worsened, required hospitalization , antibiotics, and wound debridement. Findings Include: (All times are recorded in Eastern Daylight Time.) This citation is related to intake #MI00145848. […]

• Actual harm, isolatedF686Sep 14, 2023

  This deficiency pertains to Complaint Intake #MI00138936 & #MI00137644. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing and prevent the development of pressure ulcers for four Residents (R1, R6, R30 and R51) of four residents reviewed for pressure ulcer care, out of a total sample of 15 residents. This deficient practice resulted in harm with the development of a facility acquired stage 3 pressure ulcer, the potential for delayed wound healing, infection, and deterioration of condition. […]

• Actual harm, isolatedF689Sep 14, 2023

  This citation pertains to intake MI00139217. All observations and interviews are recorded in Eastern Standard Time (EST). Based on observation, interview and record review, the facility failed to safely transfer one Resident (R56) of three residents reviewed for accidents. This deficient practice resulted in actual harm when R56 fell to the floor and sustained a right hip fracture with subsequent hospitalization , and surgical intervention. Findings include: A review of R56's Narrative and Impression Report, dated 8/29/2023, revealed the following result: 1. […]

• Actual harm, isolatedF689Aug 3, 2022

  This citation pertains to intake MI 021. All times are recorded in Eastern Daylight Time (EDT). Based on observation, interview, and record review, the facility failed to prevent a fall with fracture resulting in harm for one Resident (#29) of two residents reviewed for falls. This deficient practice resulted in decreased mobility, hospitalization , and pain. Findings include: Resident #29 Resident #29's facility incident report, dated 6/14/22, revealed she had an unwitnessed fall on 6/14/22. Orders were received for x-rays from the physician on that same day. Resident #29 expressed discomfort and complaints of pain and was sent to the local hospital. […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2025

  Based on observation, interview and record review, the facility failed to prepare food in accordance with professional standards for food service safety resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 12/2/2025 at 2:15 PM, during a kitchen tour with the Certified Dietary Manager (CDM) F it was noted that the drain line from the three-compartment sink extends down into the bowl drain causing an improper air gap. This drain line and the receiving bowl drain were noted soiled with excess food debris. When asked, CDM F stated that all dirty kitchen utensils that do not go through the dish machine are washed, rinsed and sanitized in this three-compartment sink. […]