Westgate Hills Rehab & Healthcare Ctr

Inspectors wroteBased on interview, observation, and record review, it was determined that the facility failed to have evidence that an allegation of sexual abuse was thoroughly investigated for 1(Resident #1) of 1 residents reviewed for alleged sexual abuse.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to protect the dignity of residents. This was found to be evident for 2 (5/18/2026 and 5/20/2026) out of 4 observations of the assignment board on the first floor.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to identify and notify the Resident's health care Responsible Party (RP)/Guardian of a change to the Resident's plan of care and involved them in the consent process. This was found evident in 4 (Resident #11, #4, #88 and #6) out of 76 residents reviewed for resident rights and representative involvement during the annual survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to formulate an advance directive for a resident. This was evident for 1 (Resident # 74) out of 6 residents reviewed for advance directives.

Inspectors wroteBased on record review and staff interviews, it was determined that facility staff failed to ensure a resident's representative was provided with a written notice of transfer. This deficient practice was evident for 1 (Resident #6) of 3 residents reviewed for transfer notice requirements during the annual survey.

Inspectors wroteBased on record reviews and interviews, it was determined that facility staff failed to ensure the residents' diagnosis and clinical needs were accurately captured at the time of admission and during assessment modifications. This deficient practice was evident for 2 (Resident #6, Resident #67) of 2 residents reviewed for accuracy of assessment during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop and implement patient-centered comprehensive care plans to meet the needs of residents. This was found to be evident for 1 (#13) out of 8 residents reviewed for comprehensive care plans.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings after the completion of the Minimum Data Set assessment. This was evident for 2 (Resident #4 and #88) out of 2 residents reviewed for care planning during the survey. Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team.

Inspectors wroteBased on record review and observation, it was determined that the facility failed to ensure staff maintain professional standards of practice when an active order was signed off. This was evident for 1 (Resident #9) of 3 residents reviewed for pressure ulcers.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that a resident received treatment and care in accordance with the comprehensive person-centered care plan and professional standards of practice. This was evident for 3 (Resident #11, #16 and #74) out 76 residents reviewed during the annual survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to flush a gastrostomy tube in accordance with professional standards of practice. This was found to be evident for 1 (#12) out of 1 resident reviewed for gastrostomy tube flushing.

Inspectors wroteBased on observation, medical record review, review of facility's policy and interview, it was determined that the facility staff failed to ensure residents received respiratory care consistent with professional standards of practice by providing oxygen at flow rate inconsistent with prescribed orders. This was evident for 2 (Resident #46 and #10) of 3 residents reviewed for respiratory care. Nasal cannula- a medical device used to provide supplemental oxygen therapy to people who have lower oxygen levels.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure annual performance review and regular in-service education were conducted for certified nurse aides (CNA)1. This deficient practice was evident for 2 of 5 CNA1 employee files reviewed during the annual survey.

Inspectors wroteBased on medication administration observation, medical record review and staff interview, it was determined the facility failed to ensure a medication error rate of less than 5 percent during the medication pass observation. This finding was evident for 5 medication errors out of 26 opportunities which resulted in a medication error rate of 19%. Facility stock supply medications- Are mostly common over the counter medications in multidose containers to be shared amongst residents that are prescribed those medications. Examples would be vitamins and/or supplements. Aspirin Enteric-Coated (EC) or Delayed-Release (DR) is a form of aspirin with a special coating that prevents the tablet from dissolving in the stomach. Instead, it passes into the small intestine, where it is absorbed. This form is designed to prevent stomach irritation, ulcers, and gastrointestinal bleeding.

Inspectors wroteBased on observation and interview, it was determined the facility failed to provide palatable food at an appetizing temperature. This was evident for 1 out of 1 observation of a kitchen tray line and test tray.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure food was stored in accordance with professional standards of practice for food service safety. This was evident during the initial tour of the kitchen upon entry into the facility.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility staff failed to ensure and maintain hospice documentation was available in the resident's medical records. This deficient practice was evident for 1 (Resident #3) of 2 residents reviewed for hospice services during the annual survey.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to follow standard precautions and enhanced barrier precautions. This was evident in 1) 1 (CMA #24) out of 1 staff members observed during the infection control task, 2) 1 (#6) out of 1 resident, and 3) 1 out of 2 observations of shared equipment disinfection during medication administration observed during the annual survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a resident had access to the call bell. This was evident for 2 (#1, #63, and #44) of 31 residents reviewed for call light access during the initial pool review.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to ensure staff received Quality Assurance and Performance Improvement (QAPI) training. This deficient practice was evident with 2 of 5 employee files reviewed during the annual survey.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to ensure staff received Infection control training. This deficient practice was evident with 1 of 5 employee files reviewed during the annual survey.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to ensure staff received compliance and ethics training. This deficient practice was evident with 3 of 5 employee files reviewed during the annual survey.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to post the daily required staffing information. This was found to be evident for 1 (lobby desk) out of 2 desk areas observed for staff posting.

Inspectors wroteBased on record review, interviews and complaint #2655446, it was determined that the facility failed to: 1) accurately document assessment in the resident medical record and 2) ensure that the residents receive treatment and care in accordance with professional standards of practice to prevent future skin impairment. This was evident for 2 (Resident #2, #6) of 8 residents records reviewed during the complaint process.

Inspectors wroteBased on a review of records and interviews, it was determined that the facility failed to assess or document residents' behaviors regarding mental illness. This was evident for one resident (Resident #7) out of eight residents reviewed during this complaint survey.

Inspectors wroteBased 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.

Inspectors wroteBased on record reviews and interviews, it was determined that facility staff failed to ensure a resident was free from verbal abuse. This deficient practice was evident for one (#215) resident reviewed for abuse during the complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to report an injury of unknown origin to the State Agency (SA) within the required time frame of discovering the incident, as required by regulation. This was evident for 1 out of 6 facility reported incidents during the complaint survey.

Inspectors wroteBased on record reviews and interviews, it was determined that facility staff failed to conduct a thorough investigation of alleged violations for residents. This deficient practice was evident for two (#205, #215) of sixteen residents reviewed for investigation of alleged violations during the complaint survey.

Inspectors wroteBased on interviews and record reviews it was determined that facility staff failed to provide care to a resident who was dependent on staff for personal hygiene and incontinence care. This deficient practice was evident for 1 (#201) resident reviewed for ADL care during the complaint survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to prevent an avoidable pressure injury. This was evident for 1 (Resident #208) out of 2 residents reviewed for pressure injuries. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.

Inspectors wroteBased on record review, interviews and observations, it was determined that the facility failed to ensure fall prevention interventions were in place to prevent future falls. This was evident for 1 (Resident #213) of 2 residents reviewed for falls during a complaint survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to maintain accurate resident records. This was evident for 1 (Resident #202) out of 18 residents reviewed during the complaint survey.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, and interviews, it was determined the facility failed to provide written notice with the reason for transfer of a resident. This was found evident for 1 (Resident #78) out of 3 residents reviewed for hospitalization during the survey.

Inspectors wroteBased on medical record review, and interviews it was determined the facility failed to provide the resident and/or Representative with a written notice of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 1 (Resident #78) of 3 residents reviewed for hospitalization.

Inspectors wroteBased on record review, and interviews, it was determined that the facility failed to accurately document assessments in a Resident's medical record. This was found evident of 2 (Resident #31 & #113) of 38 residents reviewed during the survey.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to inform residents of a summary of the resident's initial Baseline Care Plan (BCP) within 48 hours of the admission nor to provide a copy of initial instructions for effective and person-centered care. This was found to be evident for 1 (Resident #217) out of 3 residents for new admissions reviewed.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to develop a comprehensive person-centered care plan. This was found evident of 2 (Resident #101 & #99) out of 16 residents reviewed for falls.

Inspectors wroteBased on record review, and interview it was determined that the facility failed to conduct care plan meetings after each resident assessment and failed to invite a resident to participate in their care plan meeting. This was found evident in 2 (Residents #50 & #217) out of 4 Residents reviewed for care planning.

Inspectors wroteBased on observation, medical record review and interview, it was determined that the facility failed to provide meaningful on-going personalized activities for the residents who were confined in their rooms. This was evident for 1 (Resident #104) out of 5 residents reviewed for personalized activities.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide services to maintain a resident's vision. This was evident for 1 (Resident #66) out of 11 residents reviewed for vision during the annual recertification survey.

Inspectors wroteBased on observation, record review, and interviews it was determined that the facility failed to provide treatment to prevent further decreased range of motion for a resident. This was found evident of 1 (Resident #27) out of 5 residents reviewed for mobility.

Inspectors wroteBased on observations, interviews with staff, and record review, it was determined that the facility failed to implement an intervention, determined to be necessary, for a resident who was identified as a fall risk. This was evident of 1 (Resident #101) of 5 Residents reviewed for accidents during the annual survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to have the medical provider thoroughly review and accurately prescribe medications after a resident's readmission. This was found evident of 1 (Resident #68) out of 2 residents reviewed for pain.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to provide medication as ordered. This was evident for 1 (Resident #74) out of 5 residents reviewed for change in condition during the annual recertification survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to have a process in place that ensured a resident's medication irregularity reports were reviewed by the primary care physician and the actions taken based on the recommendations were being documented. This was found evident of 1 (Resident #50) of 5 residents reviewed for medication regimen review

Inspectors wroteBased on interview, and medical record review, it was determined that the facility failed to have a documented condition that indicated the use of psychotropic medications for a resident . This was found evident in 1 (Resident #101) out of 5 Residents reviewed for unnecessary medications.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to store medication in a locked compartment. This was found evident on 1 random observation on the second floor.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to maintain the outdoor garbage storage area in a manner to prevent the harboring pests.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure that the residents' clean clothes were stored in a manner that minimized the potential spread of infection. This was evident during the infection control investigation task of the recertification survey.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#36, #37, #42, #34) of 63 residents reviewed during a complaint survey.

Inspectors wroteBased on documentation review and interview it was determined the facility staff failed to promptly notify the physician of a resident's change in condition. This was evident for 1 (#61) of 63 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility reported incidents with documentation review and interview, it was determined the facility failed to thoroughly investigate allegation of abuse for residents (Resident #1 and #21). This was evident for 2 of 50 facility reported incidents reviewed during a complaint survey.

Inspectors wroteBased on observation, medical record review, and interviews, it was determined that the facility staff failed follow the care plan, and failed to evaluate and revise a resident's care plan to reflect accurate and current interventions. This was evident for 1 (50) of 50 resident reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on complaint, medical record review and interview, it was determined that the facility staff failed to provide needed activities of daily living for a resident dependent on assistance with care (Resident #22). This was evident for 1 of 31 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on review of complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health (Resident #27 and #1). This was evident for 2 of 31 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to provide timely treatment/services to prevent/heal pressures ulcers. This was evident for 1 (#31) of 31 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to assess and evaluate the nutrition needs of residents in a timely manner. (Resident #20). This was evident for 1 of 3 residents reviewed for weight loss during a complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication. This was evident for 1 (#54) of 31 residents reviewed for complaints.

Inspectors wroteBased on medical record review and interview, the facility staff failed to follow up with a consultant physician (Resident #22). This was evident for 1 of 63 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to keep complete and accurate medical records. This was evident for 2 (#1 and #50) of 50 residents reviewed for facility reported incidents during a complaint survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that a resident call light was accessible to him/her. This was found to be evident for 1 resident (Resident # 15) that was observed during the facility's annual survey.

Inspectors wroteBased on observations and interviews of facility staff it was determined the facility failed to ensure that residents reside in a clean, comfortable and homelike environment. This was in found to be evident during an initial tour of the facility during the facility's annual survey and has the potential to affect all the residents residing in the facility.

Inspectors wroteBased on medical records review and interview with resident and staff it was determined that the facility failed to report allegations of abuse to the appropriate state agency. This was evident for 1 of 3 residents (Resident #56) reviewed for abuse during the survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to initiate a care plan to address a resident with contractures of the right and left knee. This was evident for 1 of 43 residents (Resident #42) reviewed during the survey.

Inspectors wroteBased on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the residents' status as evidenced by failure to: 1) assess the resident's fall status and and 2a) accurately record medication usage for Anticoagulant therapy and 2b) accurately record medication usage for antipsychotic gradual dose reduction. This was found to be evident for 2 out of 29 residents (Resident #47 and #56) reviewed during the investigation stage of the survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to initiate a care plan to address resident's contractures. This was evident for 1 of 8 residents (Resident #42) in the survey sample.

Inspectors wroteBased on administrative review and interviews with the resident and facility staff it was determined the facility failed to follow the resident care plan and report when a resident was resistive to care. This was found to be evident for 1 of 3 residents (Resident #77) reviewed for allegations of abuse during the survey.

Inspectors wroteBased on observation, record review and staff interview it was determined that facility staff failed to administer the correct dosage of medication to a resident. This was found to be true for 1 of 2 residents (Resident # 67) observed for medication administration during the survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the dietitian failed to do timely assessments on residents with multiple comorbidities requiring monitoring. This was evident during the review of 2 of 4 residents (Resident #86 and Resident #29) reviewed for documented weight loss.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that a resident with as-needed pain medication regimens received pain medication according to physician prescribed orders and care plans. This was evident for 1 of 2 residents (Resident #47) reviewed for pain management.

Inspectors wroteBased on medical record review, facility competency training records and staff interview it was determined that the facility failed to ensure all licensed nursing staff had the specific competencies and skill sets necessary to care for residents with a suprapubic catheter. This was evident for 1 of 2 residents (Resident #83) reviewed for suprapubic catheter care during the survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to have the assignment board that posts the staff assignments reflective of the actual staff working. This was found to be evident for 1 of 2 hallways that were observed during the initial tour of the facility.

Inspectors wroteBased on review of medical records and interview with staff it was determined that the facility failed to: 1.) ensure pharmacist recommendations resulting from identified irregularities during the monthly pharmacy review were addressed and acted on by the physician. This was found to be evident for 1 out of the 5 residents (Resident #47) sampled for medication regimen review and 2.) failed to have time frames for the different steps in the process for the monthly drug regimen review. This was found to be evident during the unnecessary medication review during the investigative stage of the survey and has the potential to affect all the residents.

Inspectors wroteBased on observations and interviews it was determined the facility failed to: 1.) ensure that medications were kept secure as evidenced by the observation of an insulin syringes on top of a medication cart located in a hallway and 2.) keep a medication cart locked when unattended. This was found to be evident for 1 of 4 medication carts observed on the second floor and 1 of 4 medication carts observed on the first floor during the initial tour of the facility.

Inspectors wroteBased on review of pertinent facility documents and interview with facility staff, it was determined that the facility failed to develop a facility assessment that included information related to staffing needs and has has the potential to impact all residents.

Inspectors wroteBased on review of medical records, facility documentation review and staff interview it was determined the facility failed to maintain accurate documents related to: 1) the Medical Orders for Life-Sustaining Treatment (MOLST) for Resident #42; 2.) documentation that an initial assessment was completed by the dietitian when the Resident #38 was admitted and 3.) a personal belongings inventory record for Resident #468. This was evident for 3 of 43 residents reviewed during the annual survey.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility's staff failed to maintain a clean, safe and sanitary environment for residents. This finding was evident for 2 of 2 medication storage rooms, and 1 of 4 medication carts located on the first floor of the facility. This deficient practice has the potential to affect all residents in the facility.