Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westgate Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and communication barriers reported being physically abused by staff upon admission, using handwritten notes and contacting 911. Despite these efforts, staff did not immediately report the allegations to administration or authorities, resulting in a significant delay. The administrator only became aware of the situation days later and did not report the incident to the state agency until nearly three weeks after the initial allegation.
Two residents did not receive their medications as scheduled, with one experiencing repeated late administration of both morning and evening doses, and another waiting several hours for essential medications including insulin and pain relief. Staff interviews and record reviews confirmed that medications were not given within the required timeframes, and communication lapses among nursing staff contributed to the delays.
The facility failed to provide necessary care for two residents, including gastrostomy tube management and skin assessments. One resident experienced complications due to inadequate PEG tube care, leading to hospitalization. Upon return, there was insufficient documentation of the PEG tube site and missed weekly skin assessments. Another resident with a Stage IV pressure ulcer also lacked consistent skin assessments. Staff interviews revealed a lack of adherence to care protocols, highlighting deficiencies in managing residents' medical needs.
The facility failed to properly disinfect glucometers, dispose of used lancets, implement Enhanced Barrier Precautions (EBP), and ensure hand hygiene during meal tray distribution. Observations revealed inadequate PPE availability and improper infection control practices, which were confirmed by the DON.
The facility failed to ensure timely smoking privileges for two residents, with staff often being late for scheduled smoking times. Residents expressed frustration, particularly with the last smoking time of the day, which was frequently delayed by 30 minutes or more.
The facility failed to ensure accurate MDS assessments for three residents. One non-verbal resident was incorrectly documented with a BIMS score, another resident's antibiotic use was inaccurately recorded, and a third resident's discharge location was wrongly entered as a hospital instead of home. Staff interviews confirmed these errors.
The facility failed to provide appropriate catheter care for a resident with chronic kidney disease and severe cognitive impairment. Observations revealed that the catheter was not properly anchored, and there were discrepancies in the documentation of catheter changes, leading to a deficiency.
The facility failed to change the PICC line dressing for a resident as ordered, despite physician instructions for the dressing to be changed every 7 days and within 24 hours of admission, insertion, or reinsertion. The resident confirmed that the dressing had not been changed by the facility staff since admission, and the Director of Nursing acknowledged the discrepancy.
The facility failed to ensure proper oxygen and respiratory care for two residents. One resident's oxygen tubing was repeatedly found disconnected from the concentrator, and another resident's nebulizer mask was improperly stored and the machine was dirty. Staff acknowledged the issues but did not correct them.
A facility failed to implement physician-ordered blood pressure monitoring for a resident with hypertension. The resident's blood pressure was inconsistently documented, and medication was administered even when the systolic blood pressure was below the specified threshold. The Unit Manager confirmed the oversight.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Source
Penalty
Summary
The facility failed to ensure that all allegations of abuse, including injuries of unknown source, were reported immediately, as required. A resident who is deaf and mute, but cognitively intact, was admitted with multiple medical conditions including recent back surgery and was receiving anticoagulation therapy. Upon admission, the resident reported experiencing significant pain and alleged that two nurses hit her on her abdomen and back when she was unable to open her legs for care. The resident attempted to communicate her distress and allegations to staff through handwritten notes and also contacted 911, resulting in police visiting the facility. Despite these efforts, the initial allegations were not reported to the appropriate administrative staff or authorities in a timely manner. Multiple staff members, including a registered nurse and a physical therapist assistant, became aware of the resident's allegations but did not immediately escalate the report to facility administration or external authorities. The registered nurse admitted to receiving a handwritten note from the resident about the alleged abuse but assumed the next shift would handle the report and did not notify the administrator or supervisor. The physical therapist assistant eventually reported the incident to her supervisor and the administrator, but this occurred several days after the initial allegation. Facility records did not show a timely report of the abuse allegation, and the administrator only became aware of the situation after being informed by the therapist assistant. When the administrator was finally informed, she initially reported the incident to the state agency and police but later withdrew the report, categorizing it as a grievance due to perceived communication issues. It was not until nearly three weeks after the initial occurrence that the administrator interviewed the resident with an interpreter and reported the allegation to the agency. Documentation and interviews confirmed that the facility did not follow required protocols for immediate reporting of abuse allegations, resulting in a significant delay in addressing the resident's concerns.
Failure to Administer Medications Timely for Two Residents
Penalty
Summary
The facility failed to ensure timely administration of medications as ordered for two residents, resulting in multiple occurrences of late medication delivery. For one resident with severe cognitive impairment, review of the Medication Administration Record (MAR) over a 24-day period showed that scheduled 10 AM medications were repeatedly administered late, often between 11:11 AM and 12:38 PM, exceeding the facility's stated policy of administering medications within one hour before or after the scheduled time. Evening medications scheduled for 6 PM were also administered late, with times ranging from 7:28 PM to 8:43 PM. A family member reported concerns about the inconsistent timing of medication administration, and staff interviews confirmed the expectation for timely delivery was not met. Another resident, who was cognitively intact and had diagnoses including hypertension, pain, diabetes, and gastroesophageal reflux disease, did not receive scheduled morning medications, including insulin and pain medication, in a timely manner. The resident reported not receiving medications after a nurse stated she would return, and multiple observations confirmed the resident's call light remained on while she waited for assistance. Staff were observed searching for the responsible nurse, who was later found to be outside on a phone call. The resident ultimately received her medications several hours late, with pain medication administered at 11:54 AM and other scheduled medications given between 12:09 PM and 2:19 PM, well after the scheduled times. Interviews with staff, including the DON and ADON, revealed a lack of awareness regarding the nurse's absence and the delay in medication administration. The DON was not informed that the nurse would be unavailable for an extended period and was unaware that medications had not been administered to all assigned residents. The delay in medication administration was only addressed after direct intervention by other staff and surveyors, highlighting a breakdown in communication and oversight that led to the deficiency.
Deficiencies in Gastrostomy Tube Care and Skin Assessments
Penalty
Summary
The facility staff failed to provide necessary care and services for two residents, particularly concerning gastrostomy tube management and skin assessments. For one resident, there was no evidence of daily care for the PEG tube, including checking residuals or providing water flushes, as prescribed by physician orders. The resident experienced nausea and vomiting, leading to hospitalization, where it was discovered that the PEG tube had migrated, causing a partial obstruction. Upon the resident's return to the facility, there was inadequate documentation and assessment of the PEG tube site, and the staff did not complete weekly skin assessments as required. Another resident, admitted with a diagnosis of osteomyelitis and a Stage IV pressure ulcer, also did not receive consistent weekly skin assessments. The facility's records showed a lack of documentation for skin assessments over a seven-week period following the resident's readmission. This oversight in monitoring and documenting the resident's skin condition could potentially exacerbate existing pressure ulcers or lead to new skin impairments. Interviews with facility staff, including a Licensed Practical Nurse and an Advanced Registered Nurse Practitioner, revealed a lack of clarity and adherence to protocols regarding the care of gastrostomy tubes and skin assessments. The staff admitted to not having specific physician orders for the PEG tube care and acknowledged the failure to conduct thorough assessments and documentation. This lack of proper care and documentation highlights significant deficiencies in the facility's ability to provide adequate care for residents with complex medical needs.
Infection Control and EBP Deficiencies
Penalty
Summary
The facility failed to ensure proper disinfecting of glucometers for two residents. During a medication observation pass, an LPN used an alcohol pad instead of an approved disinfectant wipe to clean the glucometer and did not allow the proper wet time for disinfection. The Director of Nursing (DON) confirmed the improper disinfecting practices. Additionally, another LPN disposed of a used lancet in a resident's trash can instead of a sharps container, which was also acknowledged by the DON as improper disposal practice. The facility did not have a policy for Enhanced Barrier Precautions (EBP) and failed to implement them according to CDC guidelines. Observations revealed that rooms identified as needing EBP lacked proper signage and readily accessible personal protective equipment (PPE), specifically gowns. Multiple rooms on both floors were found without the necessary gowns, and the linen carts were inadequately stocked. The DON was made aware of these deficiencies during the survey. Hand hygiene practices were also found to be inadequate during meal tray distribution. A CNA was observed not performing hand hygiene between handling meal trays and entering different resident rooms, including a transmission-based precaution room. Additionally, two residents with conditions requiring transmission-based precautions did not have these precautions in place, as evidenced by the lack of PPE and proper signage in their rooms. The DON was informed of these issues, which were confirmed through multiple observations and interviews.
Failure to Ensure Timely Smoking Privileges
Penalty
Summary
The facility failed to ensure timely smoking privileges as per resident choice and schedule for two residents who smoke. Observations revealed that the scheduled smoking times were not consistently adhered to, with staff often being late. For instance, on one occasion, the CNA assigned to the smoking area was not present at the scheduled time, and the Unit Manager had to cover the duty. Residents expressed frustration over the inconsistency, particularly noting that the last smoking time of the day was frequently delayed by 30 minutes or more. Staff interviews confirmed these delays, with one CNA admitting to covering the smoking area to ensure residents received their smoke breaks on time. Resident #159, who was alert and oriented, and Resident #259, who had a BIMS score indicating cognitive intactness, both reported issues with the timeliness of the smoking breaks. The Assistant Director of Nursing (ADON) acknowledged the problem but downplayed the extent of the delays. Despite the ADON's claim of being vigilant about the smoking schedule, the issue persisted, particularly during the 6:30 PM smoking time, which was often delayed by the second-floor staff.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents. Resident #43, who was non-verbal and immobile, was incorrectly documented with a Brief Interview for Mental Status (BIMS) score of 6. Observations and interviews confirmed that the resident could only communicate by blinking, and the Social Services Director acknowledged the error in the BIMS assessment. Resident #3's Quarterly MDS assessment inaccurately documented antibiotic use, which was not supported by the Medication Administration Record (MAR) or corresponding orders. The MDS Director confirmed this discrepancy during an interview. Resident #108's discharge location was incorrectly recorded in the MDS assessment. Although the progress notes and discharge orders indicated that the resident was discharged home, the MDS assessment erroneously documented a discharge to the hospital. The MDS Coordinator admitted to the error, attributing it to a possible miss-click while entering the data. These inaccuracies in the MDS assessments highlight the facility's failure to ensure accurate and reliable documentation for its residents.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a clinically justified indwelling urinary catheter. Resident #42, who was admitted with chronic kidney disease and was severely cognitively impaired, had orders for catheter care every shift and to irrigate the catheter as needed for blockage, leakage, increased sediment, or decreased output. Additionally, there was an order to change and date the catheter securement device weekly. However, observations revealed that the catheter was not properly anchored, and the urine in the tubing was red-tinged, indicating potential issues that were not addressed in a timely manner. On multiple occasions, staff failed to use an anchoring device for the catheter, and the catheter tubing was observed hanging freely between the resident's thighs. The April 2024 Treatment Administration Record documented that the catheter was changed on 04/06/24, but the observed catheter was dated 03/31/24, indicating a discrepancy. The Unit Manager confirmed the inconsistency and acknowledged that the catheter should have been irrigated or changed based on the observations. These failures in catheter care and documentation led to the deficiency noted in the report.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure that the PICC line dressing for a resident was changed as ordered. The resident, who was admitted with septicemia and had a PICC line inserted for intravenous antibiotic administration, had physician orders for the dressing to be changed every 7 days and within 24 hours of admission, insertion, or reinsertion. However, the clinical records and treatment administration records indicated that the dressing was only changed on four occasions, which did not comply with the physician's orders. An observation on 04/08/24 revealed that the dressing had a date of 3/23, and the resident confirmed that the dressing had not been changed by the facility staff since admission. During an interview on 04/11/24, the Director of Nursing (DON) was made aware of the discrepancy and acknowledged the finding after a side-by-side review of the resident's record. The failure to change the PICC line dressing as ordered was confirmed, indicating a lapse in following the prescribed treatment plan for the resident, who was cognitively intact and had no mood or behavior issues as per the admission MDS assessment.
Failure to Ensure Proper Oxygen and Respiratory Care
Penalty
Summary
The facility failed to ensure proper care and services for oxygen use for two residents. Resident #59 had an order for continuous oxygen at 2 liters per minute via nasal cannula due to shortness of breath. However, multiple observations revealed that the oxygen tubing was not attached to the concentrator, and the nasal cannula was found on the floor or lying on the bed. Despite the oxygen concentrator running, the tubing was not connected, and staff members denied responsibility for the improper handling of the oxygen equipment. The resident did not report shortness of breath during these observations, but the equipment was not used as ordered by the physician. Resident #55 had orders for nebulizer treatments and the use of respiratory medications for COPD. Observations revealed that the nebulizer mask was not stored properly in a plastic bag and the nebulizer machine was dirty with debris. The mask was repeatedly found lying on top of the machine or nightstand instead of being stored hygienically. Staff acknowledged the need for cleaning or replacing the nebulizer machine and properly storing the tubing. These deficiencies indicate a failure to follow the facility's policy on oxygen administration and proper storage of respiratory equipment.
Failure to Monitor Blood Pressure as Ordered
Penalty
Summary
The facility failed to implement physician-ordered blood pressure monitoring parameters for a resident diagnosed with Essential Primary Hypertension. The resident had an order to take Lisinopril 20 mg daily, with instructions to hold the medication if the systolic blood pressure (SBP) was below 130. However, the Medication Administration Record (MAR) for January, February, March, and April 2024 showed inconsistent and insufficient documentation of blood pressure readings. Specifically, blood pressure was recorded only on a few days each month, and there were no documented readings for April until after surveyor intervention. Additionally, Lisinopril was administered on two occasions in December 2023 when the SBP was below 130. The Unit Manager confirmed that the blood pressure should have been recorded on the MAR as per the physician's order.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Palm Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Skilled Nursing Facility Llc | 0.3 mi | — | 0 | 0 |
| Darcy Hall Of Life Care | 1.3 mi | — | 2 | 0 |
| Palm Garden Of West Palm Beach | 1.5 mi | — | 1 | 0 |
| Joseph L Morse Health Center Inc The | 1.6 mi | — | 1 | 0 |
| Lakeside Health Center | 1.8 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.