Inspection Reports for
Westgate Center for Rehabilitation & Alzheimer‘s Care

F636: The facility failed to complete an Annual Comprehensive Minimum Data Set (MDS) 3.0 with Care Area Assessment (CAA) in a timely manner for 2 of 14 sampled residents, with assessments completed late by 1 and 4 days respectively.

F637: The facility failed to complete a Comprehensive Minimum Data Set (MDS) 3.0 with Care Area Assessment (CAA) for a significant change in status in a timely manner for 1 of 14 sampled residents, with the assessment completed 6 days late.

F638: The facility failed to complete a Quarterly Minimum Data Set (MDS) 3.0 in a timely manner for 7 of 14 sampled residents, with assessments completed late by 2 to 17 days.

F812: The facility failed to ensure plumbing fixtures were properly installed to prevent backflow and failed to label products in the reach-in refrigerator in the kitchen on multiple survey days.

F814: The facility failed to ensure garbage was properly disposed of and contained to prevent harborage and feeding of pests for 1 of 3 days of survey, with dumpsters observed filled with garbage bags not allowing covers to be closed.

K761: The facility failed to conduct fire door inspections that ensured fire doors are inspected, tested, and maintained in accordance with NFPA 80 and NFPA 101. Specifically, 4 of 7 sets of fire doors were not properly assessed, and a gap exceeding 1/8 inch was found between a pair of fire doors near the nurses station.

K321: The facility failed to protect hazardous area fire barrier walls and ceilings with a 1-hour fire resistance rating as required by NFPA 101 Section 19.3.5.9. Penetrations were found in the 1-hour rated fire wall in the laundry room above washing machines where electric conduit passes through. These penetrations were repaired during the inspection.

K353: The facility failed to ensure the sprinkler system was inspected, tested, and maintained in accordance with NFPA 25. A sprinkler head in the shower room near the admissions office had an escutcheon ring that was not tight to the ceiling, creating a gap that could allow smoke passage. This was repaired during the inspection.