Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 Nursing & Rehabilitation Community during CMS and state inspections, most recent first.
Licensed nursing staff failed to document the identification and treatment of a pressure injury for a resident with dementia and contractures, after being instructed by the ADON and DON not to chart the wound or notify the physician and family. Wound care was provided without a physician order or documentation for about a month, despite facility policy requiring immediate assessment, documentation, and notification. Staff interviews confirmed the wound was present and treated prior to official documentation, and the DON did not follow up on concerns raised by nursing staff.
The facility failed to prevent and manage pressure ulcers for two residents, leading to significant harm for one resident who developed a stage III pressure wound requiring hospitalization. The facility did not implement necessary preventive measures, such as regular repositioning and proper use of an air mattress, and misclassified the wound as a Kennedy ulcer, resulting in inadequate treatment.
The facility failed to provide complete NOMNC and SNF ABN forms for two residents, resulting in them not being informed of their right to appeal and potential hardships. The issue was identified during a survey and internal audits, revealing incomplete forms for selected residents.
A resident with severe cognitive impairment experienced significant weight loss, dropping from 93.7 to 86.4 pounds in one month. The facility failed to follow its protocol for monitoring and addressing weight loss, as no re-weighs or dietary interventions were conducted, and there was no dietician available at the time. The facility's policies required re-weighs and interventions for residents under 100 pounds with a weight loss of 3 pounds or more, but these were not implemented.
Failure to Document and Notify Regarding Pressure Injury
Penalty
Summary
Licensed nursing staff failed to maintain complete and accurate progress notes in accordance with accepted professional standards for a resident with dementia, a history of pressure ulcers, and contractures. The resident, who was unable to make independent medical decisions and had a Power of Attorney for Health Care, developed a pressure injury on the left iliac crest. Despite the facility's policy requiring immediate assessment, documentation, and notification upon discovery of a pressure injury, there was no documentation of the wound or wound care in the medical record prior to a specific date, even though weekly skin assessments were marked as having no areas of skin impairment. Multiple nurses reported that they were instructed by the ADON and DON not to document the wound, not to open a skin event, and not to notify the physician or the resident's family. These instructions led to the provision of wound care without a physician order and without any documentation in the resident's medical record for approximately a month. The nurses expressed discomfort and concern about the lack of documentation and the absence of physician orders, but stated they were told to follow these directives. The wound was treated with wound cleanser, Aquacel, and border foam dressings during this undocumented period. The deficiency was further substantiated by interviews with staff who confirmed the presence and treatment of the wound prior to its official documentation. The DON acknowledged being approached by a nurse about the issue but did not follow up with the ADON or investigate further. The ADON denied instructing staff to omit documentation but could not provide evidence of timely physician notification. Facility policy clearly outlined the need for immediate documentation, notification, and care planning for pressure injuries, which was not followed in this case.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement adequate measures to prevent the development and worsening of pressure injuries for two residents, resulting in significant harm to one resident. Resident 108 (R108) developed a stage III pressure wound that worsened over time, requiring hospitalization, antibiotics, and wound debridement. The facility did not provide appropriate care, as evidenced by the lack of a turning schedule, inadequate wound dressing, and failure to monitor the wound's progression. The wound care nurse misclassified the wound as a Kennedy ulcer, which led to a lack of urgency in treatment. R108 was admitted to the facility with a high risk for developing pressure wounds, as indicated by a Braden scale score of 16. Despite this, the facility did not implement necessary preventive measures, such as regular repositioning and the use of an air mattress. The wound was initially identified as a deep tissue injury, which later opened and was not properly managed. The wound care nurse and the nurse practitioner failed to provide timely and effective treatment, resulting in the wound becoming severely infected and requiring extensive medical intervention. Resident 7 (R7) also experienced inadequate care related to pressure ulcer prevention. Observations revealed that R7's air mattress was set incorrectly, and heel protectors were not used as required, leading to the resident's heels resting directly on the bed. The facility's failure to adhere to physician orders and care plans for pressure ulcer prevention contributed to the development and worsening of pressure injuries in both residents.
Failure to Provide Complete Beneficiary Notices
Penalty
Summary
The facility failed to provide a complete Notice of Medicare Non-Coverage (NOMNC) and the Advanced Beneficiary Notice of Non-Coverage (SNF ABN) for two of four residents reviewed for Beneficiary Notice. This resulted in the residents and/or their representatives not being informed of their right to appeal and the potential for emotional and financial hardships. The deficiency was identified during a survey when a SNF Beneficiary Notification Review form was provided to the facility for completion, and it was discovered that the necessary forms had not been completed for the selected residents. During interviews, the Nursing Home Administrator and the Corporate-Area Director of Utilization revealed that the facility had not completed the required NOMNC/ABN forms. The Corporate-Area Director of Utilization indicated that noncompliance was found during internal audits of Beneficiary Notification Review. The facility had identified the issue and had been conducting weekly audits since the problem was discovered, but the deficiency was still cited during the survey.
Removal Plan
- Corporate-Area Director of Utilization B educated MDS/RN C regarding completion of the NOMNC/ABN forms.
- The facility conducted weekly audits.
- The identified past noncompliance and audits will be brought to the Quality Assurance Performance Improvement (QAPI) committee for resolution.
- The facility demonstrated monitoring of the corrective action and maintained compliance.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
The facility failed to monitor and implement nutritional interventions for a resident, identified as R41, who experienced significant weight loss. R41, who was admitted with diagnoses including dementia, hypertension, fracture, and anemia, showed a severe cognitive impairment with a BIMS score of 4 out of 15. Observations noted that R41's clothes appeared large and hung loosely, indicating weight loss. The resident's weight decreased from 93.7 pounds on June 1, 2024, to 86.4 pounds on July 1, 2024, marking a 7.79% weight loss in one month. Despite this, there were no dietary progress notes or interventions documented by the Certified Dietary Manager (CDM) or Dietician in the resident's Electronic Medical Record (EMR). Interviews with the Director of Nursing (DON) and the CDM revealed that the facility's protocol for addressing weight loss was not followed. The DON stated that residents are weighed monthly, and significant weight loss should trigger re-weighs and notifications to the physician and dietician. However, the facility did not have a dietician at the time of R41's weight loss, and no re-weigh or dietary interventions were conducted. The CDM acknowledged the oversight in re-weighing and the absence of a dietician's progress note. The facility's policies required re-weighs and interventions for residents under 100 pounds experiencing a weight loss of 3 pounds or more, but these were not implemented for R41.
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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 Ironwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sky View Nursing Center | 1.3 mi | — | 0 | 0 |
| Villa Maria Health And Rehab Ctr | 1.6 mi | — | 2 | 0 |
| Gogebic Medical Care Facility | 9.9 mi | — | 0 | 0 |
| Ashland Health Services | 34.9 mi | — | 0 | 0 |
| Court Manor Health Services | 35.2 mi | — | 0 | 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.