A list of the most recent deficiencies for Westgate Gardens Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-29 | 2023-12-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-21 | 2023-08-31 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-07-31 | 2023-08-11 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-06-16 | 2023-06-23 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-04-20 | 2023-05-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-20 | 2023-05-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-20 | 2023-05-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-04-20 | 2023-05-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-04-20 | 2023-05-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-20 | 2023-05-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-20 | 2023-05-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-20 | 2023-05-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-20 | 2023-05-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-20 | 2023-05-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-20 | 2023-05-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-20 | 2023-05-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-04-20 | 2023-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-20 | 2023-05-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-20 | 2023-05-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-04-25 | 2023-05-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-25 | 2023-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-05-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-25 | 2023-05-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-25 | 2023-05-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-25 | 2023-05-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-25 | 2023-05-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-17 | 2023-05-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-02 | 2023-03-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-01 | 2023-03-16 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-07 | 2023-02-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-27 | 2023-02-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-24 | 2021-07-12 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2019-11-07 | 2019-12-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-11-07 | 2019-12-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-11-07 | 2019-12-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-11-07 | 2019-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-07 | 2019-12-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-07 | 2019-12-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-07 | 2019-12-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-07 | 2019-12-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-24 | 2019-11-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-24 | 2019-11-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-24 | 2019-11-19 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-10-24 | 2019-11-19 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-10-24 | 2019-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-24 | 2019-11-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Develop a communication plan. | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-12 | 2018-12-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-10-04 | 2018-10-31 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-10-04 | 2018-10-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-10-04 | 2018-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-04 | 2018-10-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-04 | 2018-10-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-04 | 2018-10-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-04 | 2018-10-31 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-04 | 2018-10-31 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-10-04 | 2018-10-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-10-04 | 2018-10-31 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-10-04 | 2018-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-04 | 2018-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-04 | 2018-10-31 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-10-04 | 2018-10-31 | N |
