Inspection Reports for
Westgate Gardens Care Center

The facility failed to develop a comprehensive person-centered care plan addressing cognitive impairment for one sampled resident with severe cognitive impairment. This deficiency posed a risk that staff might be unaware of the resident's cognitive needs and fail to meet them.

The complaint investigation found substantiated failures related to missed dialysis treatment notification and transportation for Resident 1, with potential health risks identified.

The facility failed to notify the attending physician when Resident 1 missed a scheduled dialysis treatment and also failed to ensure transportation was provided for the resident, resulting in missed dialysis and potential health risks.

The facility failed to follow its own policy and procedure for transferring Resident 1, resulting in the resident falling face down onto her bed due to the absence of a gait belt during transfer. Interviews and record reviews confirmed the transfer was performed inappropriately by staff.

The complaint involved an allegation that CNA 1 physically abused Resident 1 by hitting her on the head. The allegation was substantiated by interviews and progress notes. The facility suspended CNA 1 and conducted an internal investigation but failed to report the incident to outside agencies as required.

The facility failed to report an allegation of abuse involving a CNA and a resident to the Ombudsman, law enforcement, and state licensing agency within the required timeframe. Additionally, the facility failed to implement a care plan for a resident exhibiting verbally and physically abusive behavior, resulting in harm to another resident.

The complaint investigation was substantiated. Resident 1 fell during transfer with a Hoyer lift when staff failed to open the legs of the lift, causing it to tip over. Resident 1 sustained a mild displaced distal coccygeal segment fracture.

The facility failed to ensure proper use of the Hoyer lift, resulting in Resident 1 falling and sustaining a mild displaced distal coccygeal segment fracture. Staff did not open the legs of the Hoyer lift during transfer, causing it to tip over and the resident to fall.

The facility failed to ensure that home health services were arranged prior to discharge for one of three sampled residents, potentially resulting in the resident not receiving needed care after discharge. The Social Service Director could not provide evidence that home health was notified before the resident's discharge.

The facility failed to ensure that one resident was properly evaluated for self-administration of medication, resulting in lidocaine being left at the bedside without physician orders or proper safeguards.

The facility failed to notify the Ombudsman when Resident 1 was given a 30-day notice of discharge for non-payment. The facility policy requires sending a copy of the notice to the Ombudsman, which was not done.

The facility was found deficient in multiple areas including failure to respond promptly to call lights affecting resident dignity, improper labeling of medications, inaccurate documentation of meal consumption, incomplete advance directive documentation, failure to maintain functioning equipment, incomplete care plan implementation, inadequate documentation of arbitration agreement rights, and lack of attendance records for Quality Assurance meetings.

The complaint involved an allegation of sexual abuse between Resident 1 and Resident 2. The facility did not submit the required SOC 341 form to the Ombudsman or law enforcement within 24 hours as mandated. The complaint was substantiated based on interviews and record reviews.

The facility failed to provide a written report (SOC 341) of an allegation of sexual abuse between two residents to the proper authorities, violating their rights. Interviews and record reviews confirmed the lack of timely notification to the Ombudsman and law enforcement as required.

The facility failed to implement the care plan for one resident by not placing non-skid strips on the bathroom floor after a fall, which posed a potential risk for further falls.

The complaint was substantiated based on interviews with CNAs, the LVN, and the Director of Staff Development, as well as review of Resident 1's records and facility policies.

The facility failed to promptly address Resident 1's request to not have CNA 1 provide care, resulting in a violation of the resident's rights and potential emotional distress. Interviews and record reviews confirmed that CNA 1 was reassigned to Resident 1 despite the grievance.

The facility failed to notify the physician of a change in the discharge plan for one sampled resident, resulting in the physician being unaware of the resident's transfer to the hospital. Documentation and notification procedures were not properly followed according to facility policy.

The investigation was complaint-driven, focusing on Resident 1's falls and the facility's failure to revise the fall care plan. The complaint was substantiated with findings of inadequate care planning and fall prevention interventions.

The facility failed to revise and implement an appropriate fall care plan for Resident 1, who had multiple falls including a serious fall on 3/16/24 resulting in a lumbar fracture. The care plan interventions were insufficient and not updated despite repeated falls, posing potential serious harm.

The facility failed to ensure the call light was within reach for Resident 1 as required by the care plan, posing a risk that the resident could not call for assistance. Observations and interviews confirmed the call light was clipped to the wall and not accessible until adjusted by staff.

The facility failed to ensure two of three sampled residents were provided a pest-free environment, as spiders and spider webs were found in Resident 1's room, resulting in an unclean environment.

The investigation was complaint-driven, focusing on food safety concerns including serving molded food and storing expired food products. The findings substantiated the complaints with minimal harm noted.

The facility failed to ensure food served was palatable and safe, as one resident received a molded hamburger bun. Additionally, expired rice vinegar and molded Hawaiian rolls were found in the dry food storage area, posing a risk of foodborne illness.

The complaint was substantiated as the facility failed to ensure Resident 1 was discharged with her prescribed medications and instead sent home with another resident's medication.

The facility failed to ensure one of two sampled residents was discharged home with her prescribed medications, resulting in the resident receiving another resident's medication and potential for medical emergency.

The facility failed to clean and appropriately store one of four sampled residents' bed pans, posing a potential risk for contamination and infection spread.

The facility failed to ensure one of three sampled residents' medical records was provided within 2 days of being requested, resulting in a delay of 12 days. The facility's policy requires a 48-hour advance notice for providing records.

The facility had multiple deficiencies including failure to complete advance directive acknowledgement forms, failure to notify physicians of changes in resident conditions, inadequate depression assessments, incomplete PASRR screenings, improper orientation for visually impaired residents, failure to maintain continence for a fully continent resident, delayed communication of dietitian recommendations, medication administration errors, improper medication storage, failure to follow ordered diets, unsanitary kitchen conditions, and lapses in infection control practices.

The facility failed to ensure the physician was notified of a change in condition for one sampled resident, which had the potential to negatively affect the resident's health. The Director of Nursing confirmed the physician was not notified as required by facility policy.

The facility failed to implement the physician order to secure Resident 1's indwelling catheter tubing, resulting in the tubing being dislodged. The Director of Nurses confirmed the lack of documentation and implementation of the order.

The complaint involved an allegation of fiduciary abuse by Resident 4's sister, who was reportedly stealing money and denying Resident 4 access to her banking accounts. The allegation was not reported to the State Survey Agency as required. The complaint was substantiated based on interviews and record review.

The facility failed to report an allegation of fiduciary abuse to the State Survey Agency as required by policy and regulations. This failure had the potential to result in continued fiduciary abuse and harm to Resident 4 and other residents.

The facility was found deficient in multiple areas including failure to notify physicians of treatment refusals, improper medication administration via gastrostomy tube, inadequate bathing assistance, failure to honor food preferences, lack of usable assistive eating devices, and lapses in infection prevention and control practices.