Westgate Gardens Care Center

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure when a refund was not issued to one of three sampled residents (Resident 1) within 30 days. This failure resulted in a delay in Resident 1's refund.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care plan was implemented for one of three sampled residents (Resident 1) when Resident 1 request for No Male Certified Nursing Assistant (CNA) to provide care. This failure resulted in violation of Resident 1's rights and potential for emotional harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure confidentiality for one of two sampled residents (Resident 1) when the wrong Physician Orders for Life-Sustaining Treatment (POLST-form contains full name, birthdate, and treatment preference) was printed and given to Emergency Medical Services (EMS). This resulted in violation of Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to provide a clean mattress for one of six sampled residents (Resident 1). This resulted in Resident 1 sleeping on a stained mattress and potential for skin irritation and respiratory issues.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for cognition (a mental process of knowing and understanding) for one of three sampled residents (Resident 1) who had impaired cognition. This failure had the potential for staff unaware of Resident 1's cognitive impairment and not having his needs met.

Inspectors wroteBased on interview and record review, the facility failed to notify the Attending Physician (AP) for one of three sampled residents (Resident 1) when Resident 1's scheduled dialysis (a medical procedure that filters the blood of a person whose kidneys are not functioning properly) treatment was missed. This failure had the potential for fluid retention and adverse outcome.

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation was provided for one of three sampled residents (Resident 1). This failure resulted in Resident 1 missing hemodialysis treatment (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and potential for serious health risks and even death.

Inspectors wroteBased on interview and record review, the facility failed to follow their own policy and procedure for one of three sampled residents (Resident 1) when a gait belt was not used for a transfer. This failure resulted in Resident landing on her bed face down.

Inspectors wroteBased on interview and record review, the facility failed to implement its own policy when an allegation of abuse for one of three sampled residents (Resident 1) was not reported to Ombudsman, law enforcement, and state licensing agency. This failure had the potential to put residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement the care plan for one of five sampled residents (Resident 4) when staff witnessed Resident 4 invading Resident 5's personal space looking angry and aggressive and did not intervene. This failure resulted in Resident 4 cussing at and hitting Resident 5 on the left leg.

Inspectors wroteBased 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).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) home health services were set up prior to discharge. This failure had the potential to result in Resident 1 not receiving the assistance and care she needed upon discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was evaluated to self-administer medication when lidocaine (medication used to relieve pain) was left at the bedside. This failure resulted in Resident 1 having medication at bedside and the potential to self-administer medication incorrectly.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Ombudsman (government-appointed official who investigates and attempts to resolve complaints in the long-term care facility) was notified when one of three sampled residents (Resident 1) was provided a 30-day notice to discharge the facility for non-payment. This failure had the potential for Resident 1 to experience an inappropriate discharge.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to document the attendance of Quality Assurance and Performance Improvement (QAPI) committee meetings during ten of 12 meetings in 2024. This failure prevented the verification of attendance of the required QAPI committee members (Administrator, Director of Nursing, Medical Director, and Infection Preventionist).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 12 sampled residents (Resident 97, Resident 34, and Resident 13) were treated with dignity when they had to wait up to two hours for their call light request to be answered. This failure resulted in residents experiencing discomfort and feeling upset and the potential for skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of 64 sampled residents (Resident 42 and Resident 101). This failure had the potential to result in residents' needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functioning overhead light was provided for one of eight sampled residents (Resident 37). This failure resulted in Resident 37 to not have a light available for personal use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow one of eight sampled residents (Resident 103) care plan for smoking. This failure had the potential to result in Resident 103 to not meet his psychosocial (a person's well-being) needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled for one of seven residents (Resident 83) when two of Resident 83's medications were labeled with the wrong type of insulin and the wrong resident's name. These failures had the potential for Resident 83 to receive the wrong insulin, another resident's insulin or another resident to receive a medication without a physician order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 93 and Resident 103) meal consumption percentages were documented accurately. This failure had the potential to resulted in Resident 93 and Resident 103 to experiencing unplanned weight loss or weight gain.

Inspectors wroteBased on interview and record review, the facility failed to provide a written report of an allegation of sexual abuse to the proper authorities for two of three sampled residents (Resident 1 and Resident 2). This violated Resident 1 and Resident 2's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan was implemented for one of two sampled residents (Resident 1) when non-skid strips were not placed on the bathroom floor after a fall. This failure had the potential to result in further falls.

Inspectors wroteBased on interview and record review, the facility failed to promptly resolve one of three sampled residents (Resident 1) grievance when Resident 1 requested for Certified Nursing Assistant (CNA 1) to not return to his room and provide care. This failure resulted in violation of Resident 1 ' s rights and potential for emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when there was a change in the discharge plan for one of three sampled residents (Resident 1). This failure resulted in the physician being unaware of Resident 1's transfer to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to revise and implement an appropriate plan of care for falls for one of three sampled residents (Resident 1). This failure had the potential to cause serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan was implemented when the call light was not within reach for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to be unable to call for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were provided a pest free environment when a spider and spider webs were on the bedroom furniture. This failure resulted in an unclean environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advance Directive (AD-health care preferences, including decisions for end-of-life care) acknowledgement form was completed for nine of 13 sampled residents (Resident 13, Resident 71, Resident 64, Resident 106, Resident 33, Resident 17, Resident 66, Resident 70, and Resident 82). This failure had the potential for the licensed staff to be unaware of the desired medical treatment when residents' are no longer able to make decisions in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to refer promptly three of five sampled residents (Resident 17, Resident 41, Resident 108) for a level II mental health services as indicated in the positive pre-admission screening and resident review report I (PASRR Level I identifies if an individual has a suspected Mental Illness [MI] or an intellectual/Development Disability or Related Condition [ID/DD/RR]. It's an evaluation data requirement to determine whether a resident with mental illness requires specialized services). This failure had the potential for residents to decline in their mental capacity and not receive specialized services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than 5% for three of 14 sampled residents (Resident 36, Resident 45, Resident 335). This failure had the potential for adverse health outcomes related to incorrect medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure medications were properly labeled and stored in one of three sampled medication carts (Cart 2). This failure had the potential to result in medications being administered to the wrong resident and not being stored in accordance with manufacturers recommendations. 2. Ensure that controlled substances were stored in accordance with federal and state laws and regulations. This failure had the potential to result in drug diversion (transfer of a legally prescribed controlled substance from the individual for whom it was prescribed to another person for illegal use). 3. Maintain the recommended temperature range for medications stored in one of two medication refrigerators. This failure had the potential to result in medications losing their effectiveness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure professional standards for food service safety and sanitary kitchen conditions. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) for at-risk vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices when: 1. Used linens were not handled correctly for one of one sampled resident (Resident 92). 2. Handwashing was not performed before and after treatment/procedure for two of two sampled residents (Resident 9 and Resident 107) These failures had the potential for the spread of infections to residents, staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physicians of a change in condition for two of two sampled residents (Resident 74 and Resident 33). This failure had the potential for a delay in appropriate patient care for Resident 74 and Resident 33.

Inspectors wroteBased on interview and record review, the facility failed to routinely assess depression (mental illness marked by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) for one of seven sampled residents (Resident 66). This failure had the potential for Resident 66's depression to go untreated.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR- assessment to ensure facility services are appropriate for people with mental illness, developmental disabilities, substance abuse disorders, or have a conservator) was completed for one of one sampled resident (Resident 70). This failure had the potential for not providing the appropriate care and treatment to Resident 70.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one visually impaired resident (Resident 82) was properly oriented to her meal tray and hot drink. This failure had the potential to negatively impact Resident 82's dignity and for her to accidentally spill her hot drink on herself.

Inspectors wroteBased on interview and record review, the facility failed to ensure a fully continent (aware and able to control bowel and bladder function) resident was assisted with toileting needs to maintain continence for one of one sampled resident (Resident 118). This failure had the potential for Resident 118 to lose bowel and bladder continence and to negatively impact her dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Registered Dietitian's (RD) nutrition intervention recommendation was communicated to the physician in a timely manner for one of four sampled residents (Resident 50). This failure resulted in Resident 50's unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen therapy was followed for one of six sampled resident (Resident 33). This failure had the potential for Resident 33 to have complications related to inadequate oxygen administration.

Inspectors wroteBased on interview and record review, the facility failed to clarify with RD/Physician a duplicate order for a protein supplement for one of one sampled resident (Resident 103). This failure resulted in Resident 103 receiving more than the intended amount of the protein supplement and had the potential to result in undesired weight gain.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the ordered diet menu to meet the nutritional needs for three of 133 sampled residents (Resident 24, Resident 58, and Resident 93). This failure resulted in unmet nutritional needs for at-risk vulnerable residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician regarding refusal of treatment for one of 44 sampled residents (Resident 339). This failure had the potential to result in unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medication via gastrostomy tube (G-tube - a tube inserted through the abdomen directly into the stomach, used to provide nutrition, fluids, and medication to people unable to take these things orally) as per the physician's order (PO) for one of 44 sampled residents (Resident 112). This failure had the potential to result in inadequate medication absorption for Resident 112.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 44 sampled residents (Resident 129) received routine bathing. This failure had the potential to negatively impact Resident 129's health and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences were honored for one of 44 sampled residents (Resident 130). This failure had the potential to result in decreased nutritional intake for Resident 130.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure usable assistive devices were available to one of 44 sampled residents (Resident 3). This failure had the potential to negatively impact Resident 3's nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection prevention and control practices when: 1. Hand hygiene was not performed prior to assisting one of 44 sampled residents (Resident 46) with eating; 2. Resident care equipment was not maintained in a sanitary manner for one of 44 sampled residents (Resident 37). These failures had the potential to result in the spread of infection.