Westgate

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care to promote the prevention and healing of pressure ulcers when staff failed to assess, monitor, document, and notify the physician for at least 17 days of a newly acquired Stage 4 (full thickness tissue loss with exposed bone) pressure ulcer that developed on one resident's (Resident #1) sacrum (the triangular bone located above the tailbone) which resulted in the resident requiring prolonged antibiotic treatment for probable osteomyelitis (an infection and inflammation of the bone typically caused by bacteria or fungi) and when staff failed to complete a wound treatment per physician order, and timely assess, document and notify the physician of five newly acquired pressure ulcers for one resident (Resident #2) in a selected sample of 10 residents. The facility's census was 100 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care to promote the prevention and healing of skin breakdown when staff failed to timely and accurately assess and document related to Moisture Associated Skin Damage (MASD-inflammation and skin erosion caused by prolonged exposure to bodily fluids such as urine and feces) for one resident (Resident #3) in a selected sample of 10 residents. The facility's census was 100 residents. Review of the facility's Wound and Skin Care Protocol, revised November 2024, showed the following information:-Purpose to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse by staff when one staff (Certified Nursing Assistant (CNA) A) physically pushed the resident's face. The facility census was 109. Based on interviews and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse by staff when one staff (Certified Nursing Assistant (CNA) A) physically pushed Resident #1's face. The facility census was 109. On 01/08/26, facility management became of the noncompliance that occurred on 01/08/26. The facility reported the allegation, began an investigation, took steps to protect the residents, and began facility-wide in-service regarding abuse, neglect, dignity, and respect; began monitoring the resident for any psychosocial changes; [...]

Inspectors wroteBased on record review, observation, and interview the facility failed ensure all residents were treated with dignity and respect when one staff (Licensed Practical Nurse D) grabbed one resident's arm (Resident #1) and grabbed food out of the resident's hand. The facility's census was 109. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of record keeping to ensure all controlled substances (substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) were accurately accounted for when staff did not accurately document all administrations of and could not easily reconcile the balance of a controlled medication for one resident (Resident #1) out of four sampled residents. The facility census was 110. The facility Administrator and the Assistant Director of Nursing (ADON) were notified of the Past Non-Compliance which occurred on 11/28/24. The facility staff began an investigation on 12/12/24 when the medication reconciliation error was found. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for all residents when staff failed to maintain the cleanliness of the the bathrooms of six residents (Resident's #51, #89, #32, #36, #39 and #102). The facility census was 108. Review showed the facility did not provide a policy that related to cleaning and maintain the bathrooms in residents' rooms. Review of the facility's cleaning sheet titled, Housekeeping 3 (300 hall), undated, showed the following: -Five step procedure for rooms included pull trash/sanitize can/replace liner, horizontal surfaces, vertical surfaces, dust mop, and damp mop; -Seven step procedure for bathrooms included check/refill supplies, pull trash/sanitize can/replace liner, dust mop/sweep, clean sink area/tub, clean commode/base, clean walls/partitions, and damp mop; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications were stored per standards of practice when staff walked away and out of view of an unlocked medication cart containing resident medications. The facility census was 108. Review of the facility policy titled Administering Medications, revised 12/12, showed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse 1. Observation on 06/05/24, beginning at 2:45 P.M., showed Certified Medication Technician (CMT) D prepared medications for multiple residents and placed the cups containing the medication in the top drawer of the medication cart. The CMT then walked away from the medication cart without locking the care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medical records were maintained in a confidential fashion when staff left the computer on medication cart unlocked, unattended, and visible to other for one resident (Resident #5). The facility census was 108. 1. Review of Resident # 5's face sheet showed the following information: -admission date of 05/06/24; -Diagnosis included hypertension (high blood pressure), diabetes, and chronic kidney disease. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/06/24, showed the resident had moderate cognitive impairment. Observations on 06/05/24, starting at 2:45 P.M., showed Certified Medication Technician (CMT) D prepared medication for the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to share a room with his or her roommate of choice and the right to receive written notice of the room change, including the reason, were protected when staff moved one resident (Resident #1) to a room on a different hall without a written notice issued or documentation of the resident's consent to the change. The facility had a census of 105. Review of the facility's policy titled, Room Change/Roommate Assignment, revised March 2021, showed the following information: -Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents received adequate supervision to prevent possible accidents when staff failed to respond to an alarm when one resident (Resident #1) left the facility at night, was found by a neighboring facility's staff, and suffered a fall with injury, and when the facility staff failed to have a process in place, and ensure all staff were trained on the process, to routinely check wander prevention devices to ensure they worked correctly for two residents (Resident #1 and Resident #2). The facility had a census of 101. Review of a facility policy titled, Wandering and Elopements, revised March 2019, showed the following information: -The facility is to identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with standards of practice when staff failed to document a fall or complete post fall monitoring for one resident (Resident #3's) who suffered fall, resulting in a possible delay of identification of injury of a hip fracture. The facility census was 101. Review of a facility policy titled, Accidents and Incidents-Investigating and Reporting, revised July 2017, showed the following: -All accidents and incidents involving residents are to be investigated and reported to the Administrator; -The nurse supervisor, charge nurse, department director, or supervisor shall promptly initiate and document investigation of the accident or incident; [...]

Inspectors wroteBased on interview and record review, the facility failed to provided showers as preferred for nine residents (Resident #5, #13, #16, #39, #41, #68, #69, #74, and #78). The facility census was 89. Record review of the facility's policy titled Resident Bathing, undated, showed the staff shall provide person-centered care that emphasizes the resident's comfort, independence and personal needs and preferences. 1. During the resident group meeting held on 7/18/22, at 1:55 P.M., showed the following: -There were eight residents who attended the meeting; -The residents all agreed that they did not receive showers/baths on a regular basis and did not get two showers a week; -Resident #74 said he/she went three weeks without a shower and was finally given one last Wednesday or Thursday. He/she would really like to have a bath at least two times a week; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete criminal background checks (CBC) or Family Care Safety Registry (FSCR) for two staff (Dietary Aide (DA) S and Licensed Practiced Nurse (LPN) R); failed to completed employee disqualification list (EDL) checks for four sampled staff (Registered Nurse (RN) Q, DA S, LPN R, and Housekeeper U); [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered care plan, that includes measurable objectives to meet the resident's medical and nursing needs identified in the comprehensive assessment for three residents (Residents #5, #50, and #78). The facility census was 89. Record review of a facility policy entitled Care Plan, Comprehensive Person-Centered, revised December 2016, showed the following information: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The care plan will: -Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide weekend activities that met the needs and interests of the residents in and out of the SCU (specialized care unit in long-term care facilities developed to provide specialized care for individuals living with dementia). Facility census was 89. Record review of the facility's policy for resident activities titled Group Programs and Activity Calendar, dated June 2018, showed the following: -Group activities are available in this facility and an activity calendar is completed and maintained to inform residents, families, and staff of the activity opportunities available; -Both large and small group activities are part of the activity programs; -The activity calendar states all activities available for the entire month, which may also include scheduled in-room activities; [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to document a pre-use assessment, obtain informed consent, and obtain a physician's order for the use of bed rails for five residents (Residents #22, #46, #50, #51 and #72). The facility failed to care plan the use of side rails for four residents (Residents #46, #50, #51, and #72) The facility census was 89. Record review of a facility policy entitled Proper Use of Side Rails, revised December 2016, showed the following information: -The purposes of these guidelines are to ensure the safe use of side rails as resident mobility; -Side rails are only permissible if they are used to treat a resident's condition and circumstances; -An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to keep food safe from potential contamination when food contact surfaces (dishes) were stacked wet instead of air dried, potentially causing bacteria growth and when staff failed to date or label stored food after opening. The facility census was 89. 1. Record review of the facility policy titled Dishwashing: Machine Operation, by Health Technologies, Inc. Guideline and Procedure Manual, 2016 Edition, showed the following information: -Use clean, washed hands to pull out clean racks, and allow to dishes to air dry before putting dishes away for storage; -The pots and pans will be drained and air dried on the drain counter. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed the following information: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control guidelines related to hand washing when providing personal hygiene care for two residents (Residents #51 and #72) and during a medication pass for five observed residents (Resident #5, #16, #41, #50, and #72). The facility census was 89. Record review of a facility policy entitled Handwashing/Hand Hygiene, revised August 2019, showed the following information: -The facility considers hand hygiene the primary means to prevent the spread of infections; -Wash hands with soap and water when hands are visibly soiled; -Use an alcohol-based hand rub or soap and water before and after direct contact with residents; before preparing or handling medications; before donning sterile gloves; before handling clean or soiled dressings; [...]

Inspectors wroteBased on observation, interview, and record review the facility to be adequately equipped with a full call light system when staff stored emergency call light pull cords where residents could not access the pull cord to call for staff assistance. The facility census was 89 residents. Record review of the facility's policy titled Answering the Call Light, dated March 2021, showed the following: -The purpose of this procedure is to ensure timely responses to the resident's requests and needs; -Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident; -Ask the resident to return demonstration; -Explain to the resident that a call system is also located in his/her bathroom; -Be sure that the call light is plugged in and functioning at all times; -Report all defective call lights to the nurse supervisor promptly. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a hospital transfer for two residents (Resident #1 and Resident #50) out of 23 sampled residents. The facility census was 89. Record review of the facility policy Transfer or Discharge Notice, dated March 2021, showed the following information: -The resident and representative are notified in writing of the following information: -The specific reason for the discharge or transfer -The effective date of the transfer or discharge; -The location to which the resident is being transferred or discharged ; -An explanation of the resident's rights to appeal the transfer or discharge to the state; -The facility bed-hold policy; -The names and contact information for the Office of the State of Long-term Care Ombudsman; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident #83 and #72) received showers/baths as needed to maintain good personal hygiene. The facility census was 89. Record review of the facility's policy titled Resident Bathing, undated, showed the staff shall provide person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences. 1. Record review of the Resident #83's face sheet (gives basic profile information) showed the following information: -admission date of 6/10/22; -Diagnoses included malignant neoplasm (tumor) of brain, morbid (severe) obesity due to excess calories, muscle weakness, unsteadiness on feet, altered mental status, abnormality of gait and mobility, need for assistance for personal care, and cognitive communication deficit. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure appropriate safe medication administration, per standards of practice and facility policy, when staff left medication at the bedside of one resident (Resident #13). The facility had a census of 89. Record review of the facility policy, Administering Medications, dated April 2019, showed the following information: -Medications are administered in a safe and timely manner, and as prescribed; -Medication are administered in accordance with prescriber orders, including any required time frame; -For residents not in their rooms or otherwise unavailable to receive medication on the pass, the Medication Administration Record (MAR) may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer medication; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure staff accurately documented colostomy care for one resident (Resident #50) and failed to remove a wound vac (suction pump, tubing and a dressing use to remove excess fluid and promote healing in wounds) orders and continued to document the wound vac, that was not in place, was changed twice per week for one resident (Resident #50). The facility had a census of 89. Record review showed the facility policy Colostomy/Ileostomy Care, dated October 2010, showed the following information: -The purpose of the procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter; -Review the resident's care plan to assess for any special needs of the resident; -Assemble the equipment and supplies as needed; -Supplies needed, steps in the procedure; [...]