Inspection Reports for Westgate Villa Assisted Living

The inspection visit was an unannounced case management visit conducted following an incident report received on 07/17/2025 regarding the management of resident R1's funds by a family member.

The Executive Director reported that resident R1 has not paid monthly rent since May 2025, and the family member managing the funds has not made payments despite promises and notifications. The facility plans to hold a conference with the family member if payment is not received by August 2, 2025, and the Licensing Program Analyst will follow up in August 2025.

The inspection was an unannounced required 1-year annual inspection conducted by the Licensing Program Analyst.

The facility was toured and inspected, including resident bedrooms, common areas, and safety equipment. No deficiencies were cited. Resident and staff files were reviewed and found complete and up-to-date. The facility maintains proper emergency plans and training.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 11/29/2022 regarding the facility's care and services to residents, including housekeeping, basic care needs, adherence to doctor's notes, menu provision, and infection control.

The investigation found no evidence to substantiate the allegations. Facility staff met residents' housekeeping and basic care needs, followed doctor's orders, provided weekly menus with daily menus available, and appropriately isolated sick residents. Staffing levels were sufficient, and no evidence of staff threatening residents or serving raw meat was found. Some residents reported missing clothes after laundry, but the facility took actions to improve laundry scheduling to prevent this.

The complaint investigation was unannounced and included allegations about unmet housekeeping needs, basic care needs, failure to follow doctor's notes, lack of daily menus, mixing sick and uninfected residents, nutritional needs not met, serving raw meat, verbal altercation and threats by staff, missing resident items, and insufficient staffing. The investigation concluded all allegations were unsubstantiated or unfounded.

The visit was an unannounced case management visit to follow up on resident R1, who was admitted after the previous facility was closed due to a Temporary Suspension Order (TSO).

The Licensing Program Analysts toured the resident's room, bathroom, kitchen, and pantry, observing adequate living conditions and food supplies. The facility staff is working with the resident's responsible party and physicians to obtain necessary documents and has assigned a 1:1 caregiver at night for three days to monitor the resident. No deficiencies were cited.

The inspection was a required unannounced annual inspection to evaluate compliance with licensing regulations.

The facility was inspected thoroughly including resident and staff files, physical environment, safety equipment, and food supplies. No deficiencies or violations were explicitly noted in the report.

The inspection was conducted as an unannounced complaint investigation following allegations that residents were not provided an adequate amount of showers and were left soiled for a long period of time.

Based on interviews with residents, staff, and review of documents, the Department found that residents received at least two showers per week and could request more if needed. Staff checked residents' diapers every two hours and changed them as necessary. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint included allegations that residents were not provided adequate showers and were left soiled for long periods. The investigation found these allegations unsubstantiated after interviews and document review.

The inspection was a required, unannounced annual inspection conducted to evaluate the facility's compliance with licensing regulations.

The Licensing Program Analyst conducted a thorough inspection of the facility, including resident and staff file reviews, facility tour, and safety equipment checks. The facility was found to have sufficient food supplies, properly serviced fire extinguishers, functioning smoke detectors, and no obstructions in walkways. Room and hot water temperatures were within acceptable ranges.

The inspection was a required unannounced annual inspection to evaluate the facility's compliance with licensing regulations.

The inspection found the facility generally compliant with no citations issued. Infection control measures were observed, including sufficient PPE and food supplies, social distancing of beds, and hand sanitizers. Some public restrooms lacked posters on hand washing, which were posted before the inspector left.

An unannounced Case Management visit was conducted for an exception request regarding the prohibited health condition of a resident.

The Licensing Program Analyst observed the resident requiring 24/7 oxygen, assistance with mobility, incontinence care every two hours, feeding, dressing, grooming, toileting, showering twice weekly, and medication management. The resident has been at the facility for 8 years with family support for continued stay.

The inspection was conducted as a complaint investigation following an allegation that a staff member hit a resident at the facility.

The investigation included interviews with staff, residents, family members, and the resident's doctor, as well as review of relevant records. The allegation was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that a staff member hit a resident. Multiple interviews with staff, residents, family members, and the resident's doctor found no evidence or observations supporting the allegation. The resident was assessed with no signs of injury. The allegation was determined to be unsubstantiated.

The visit was an unannounced complaint investigation triggered by an allegation of staff physically abusing a resident.

The investigation included interviews with residents, staff, and medical professionals, as well as review of medical records and facility documentation. The allegation of physical abuse was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff physically abused a resident. Interviews with residents, staff, and the resident's orthopedic doctor, along with medical record reviews, found no evidence of abuse. The resident had a history of fragility fractures and low bone density. The allegation was determined to be unsubstantiated.

The inspection was a required unannounced annual inspection to evaluate compliance with licensing regulations, including COVID-19 infection control measures.

The facility was generally compliant with infection control practices and environmental conditions; however, a deficiency was cited due to some staff not washing their hands when entering the facility during surveillance testing.

The visit was a Case Management - Other type conducted via tele-visit due to COVID-19 preventive measures, focusing on facility compliance with infection control and safety protocols.

No deficiencies were cited during the tele-visit. The facility demonstrated compliance with COVID-19 preventive measures including PPE availability, staggered meal schedules, and social distancing. Several clinical consultant recommendations were provided to improve safety and hygiene practices.