Table of Contents
Westgate Nursing Home
Inspection Report, Updated April 2013
PFI: 0470
Regional Office: WRO--Rochester Area Office
This report displays citations for the three most recent Certification Surveys, and citations for Complaint Surveys during the past three years.
Summary
This table summarizes the citations in the details section of this report and compares them against the statewide average.
| Measure | This Facility | Statewide Average |
|---|---|---|
| Standard Health Deficiencies | 73 | 18 |
| Life Safety Code Deficiencies | 21 | 7 |
| Total Deficiencies | 94 | 25 |
| Deficiencies Related to Actual Harm or Immediate Jeopardy | 1 | 1 |
| % of Deficiencies Related to Actual Harm or Immediate Jeopardy | 1% | 4% |
Details of Certification and Complaint Surveys
Key to understanding citations and surveys:
Potential for no more than Minimal Harm
Potential for more than Minimal Harm
Actual Harm
Immediate Jeopardy
Isolated
Pattern
Widespread
- Certification surveys are on-site inspections required every 9-15 months by the federal government.
- Complaint surveys are on-site inspections held as the result of a complaint. They are only shown here if they resulted in a citation.
August 3, 2012 Complaint Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity  | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
RESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE  | | |  | September 10, 2012 |
| ASSESSMENT AFTER A SIGNIFICANT CHANGE | | | | September 10, 2012 |
| ESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION | | | | September 10, 2012 |
| PROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES | | | | September 10, 2012 |
April 25, 2012 Certification Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| FACILITY MAINTAINS QA COMMITTEE | | | | June 18, 2012 |
| CRIMINAL HISTORY RECORD CHECK NOT PERFORMED PROVIDER SHALL SUBMIT REQUEST FOR CHECK | | | | June 18, 2012 |
| CRIMINAL HISTORY RECORD CHECK TEMPORARY APPROVAL PENDING RESULTS/ SUPERVISION REQUIRED | | | | June 18, 2012 |
| FACILITY IS FREE OF ACCIDENT HAZARDS | | | | June 18, 2012 |
| PROPER LABELING OF DRUGS AND BIOLOGICALS | | | | June 18, 2012 |
| ACCESS TO TELEPHONE WITH AUDITORY PRIVACY | | | | June 18, 2012 |
| ACCOMMODATION OF NEEDS AND PREFERENCES | | | | June 18, 2012 |
| ACTIVITY PROGRAM MEETS INDIVIDUAL NEEDS | | | | June 18, 2012 |
| DEVELOP COMPREHENSIVE CARE PLANS | | | | June 18, 2012 |
| FACILITY ESTABLISHES INFECTION CONTROL PROGRAM | | | | June 18, 2012 |
| FREQUENCY AND TIMELINESS OF PHYSICIAN VISIT | | | | June 18, 2012 |
| HOUSEKEEPING AND MAINTENANCE SERVICES | | | | June 18, 2012 |
| NOT EMPLOY PERSONS GUILTY OF ABUSE | | | | June 18, 2012 |
| RESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS | | | | June 18, 2012 |
| RIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES | | | | June 18, 2012 |
| SERVICES BY QUALIFIED PERSONS IN ACCORDANCE WITH CARE PLAN | | | | June 18, 2012 |
| SERVICES PROVIDED MEET PROFESSIONAL STANDARDS | | | | June 18, 2012 |
| ESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION | | | | June 18, 2012 |
| INFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC. | | | | June 18, 2012 |
| NURSE STAFFING | | | | June 18, 2012 |
| SELF-DETERMINATION - RESIDENT MAKES CHOICES | | | | June 18, 2012 |
| STANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME | | | | June 18, 2012 |
Standard Life Safety Code Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| CONSTRUCTION TYPE | | | | June 18, 2012 |
| VENTILATING EQUIPMENT | | | | June 18, 2012 |
| EXIT ACCESS | | | | June 18, 2012 |
| EXIT PARTITIONS | | | | June 18, 2012 |
| FIRE DRILLS | | | | June 18, 2012 |
| HAZARDOUS AREAS - SEPARATION | | | | June 18, 2012 |
| OTHER | | | | June 18, 2012 |
| STAIRWAY ENCLOSURES AND VERTICAL SHAFTS | | | | June 18, 2012 |
| SPACE HEATERS | | | | June 18, 2012 |
November 21, 2011 Complaint Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| DEVELOP COMPREHENSIVE CARE PLANS | | | | January 10, 2012 |
June 17, 2011 Certification Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| FACILITY ESTABLISHES INFECTION CONTROL PROGRAM | | | | August 9, 2011 |
| STORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS | | | | August 9, 2011 |
| CRIMINAL HISTORY RECORD CHECK DOH NOTICE OF PROPOSED DISAPPROVAL/DIRECT CARE & SUPERVISION PROHIBITED | | | | August 9, 2011 |
| HOUSEKEEPING AND MAINTENANCE SERVICES | | | | August 9, 2011 |
| MAINTAINS EFFECTIVE PEST CONTROL PROGRAM | | | | August 9, 2011 |
| PROPER LABELING OF DRUGS AND BIOLOGICALS | | | | August 9, 2011 |
| RESIDENT CALL SYSTEM | | | | August 9, 2011 |
| SUFFICIENT NURSING STAFF ON A 24-HOUR BASIS | | | | August 9, 2011 |
| ADL CARE PROVIDED FOR DEPENDENT RESIDENTS | | | | August 9, 2011 |
| DEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN | | | | August 9, 2011 |
| DIGNITY | | | | August 9, 2011 |
| ESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION | | | | August 9, 2011 |
| FACILITY IS FREE OF ACCIDENT HAZARDS | | | | August 9, 2011 |
| FACILITY PROHIBITS ABUSE, NEGLECT | | | | August 9, 2011 |
| FACILITY RESOLVES RESIDENT GRIEVANCES | | | | August 9, 2011 |
| NOT EMPLOY PERSONS GUILTY OF ABUSE | | | | August 9, 2011 |
| POLICIES, PROCEDURES PROHIBIT ABUSE, NEGLECT | | | | August 9, 2011 |
| PROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES | | | | August 9, 2011 |
| RESIDENT RECEIVE TREATMENT TO MAINTAIN HEARING/VISION | | | | August 9, 2011 |
| SELF-DETERMINATION - RESIDENT MAKES CHOICES | | | | August 9, 2011 |
| SERVICES BY QUALIFIED PERSONS IN ACCORDANCE WITH CARE PLAN | | | | August 9, 2011 |
| SERVICES PROVIDED MEET PROFESSIONAL STANDARDS | | | | August 9, 2011 |
| DEPARTMENT CRIMINAL HISTORY REVIEW AUTHORIZED PERSON(S)/CONFIDENTIALITY OF INFORMATION | | | | August 9, 2011 |
| STANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME | | | | August 9, 2011 |
Standard Life Safety Code Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| CONSTRUCTION TYPE | | | | August 9, 2011 |
| VENTILATING EQUIPMENT | | | | July 11, 2011 |
| GENERATORS INSPECTED/TESTED | | | | August 9, 2011 |
| OTHER | | | | August 9, 2011 |
| SMOKE PARTITION CONSTRUCTION | | | | August 9, 2011 |
| TESTING OF FIRE ALARM | | | | August 9, 2011 |
April 5, 2011 Complaint Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| ASSESSMENT AFTER A SIGNIFICANT CHANGE | | | | May 15, 2011 |
| DEVELOP COMPREHENSIVE CARE PLANS | | | | May 15, 2011 |
January 18, 2011 Complaint Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| NOT EMPLOY PERSONS GUILTY OF ABUSE | | | | February 1, 2011 |
| PROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING | | | | February 1, 2011 |
November 26, 2010 Complaint Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| ADL CARE PROVIDED FOR DEPENDENT RESIDENTS | | | | January 13, 2011 |
| ENVIRONMENT IS SAFE/FUNCTIONAL/SANITARY/COMFORTABLE | | | | January 18, 2011 |
| FACILITY ESTABLISHES INFECTION CONTROL PROGRAM | | | | January 18, 2011 |
November 4, 2010 Complaint Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| FACILITY IS FREE OF ACCIDENT HAZARDS | | | | December 28, 2010 |
| SERVICES PROVIDED MEET PROFESSIONAL STANDARDS | | | | December 28, 2010 |
June 10, 2010 Certification Survey
View Statement of Deficiencies issued for this Inspection Cycle
Standard Health Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| STORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS | | | | July 28, 2010 |
| ACTIVITY PROGRAM MEETS INDIVIDUAL NEEDS | | | | July 28, 2010 |
| CORRIDORS HAVE FIRMLY SECURED HANDRAILS | | | | July 28, 2010 |
| DIGNITY | | | | July 28, 2010 |
| HOUSEKEEPING AND MAINTENANCE SERVICES | | | | July 28, 2010 |
| MAINTAINS EFFECTIVE PEST CONTROL PROGRAM | | | | July 28, 2010 |
| FACILITY ESTABLISHES INFECTION CONTROL PROGRAM | | | | July 28, 2010 |
| MEDICALLY RELATED SOCIAL SERVICES | | | | July 28, 2010 |
| SERVICES PROVIDED MEET PROFESSIONAL STANDARDS | | | | July 28, 2010 |
| STANDARDS OF CONSTRUCTION FOR NEW EXISTING NURSING HOME | | | | July 28, 2010 |
| PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS | | | | July 28, 2010 |
| PROPER LABELING OF DRUGS AND BIOLOGICALS | | | | July 28, 2010 |
| RESIDENT INFORMED OF HEALTH STATUS AND MEDICAL CONDITION | | | | July 28, 2010 |
Standard Life Safety Code Inspection
| Deficiency | Severity | Residents Affected | Substandard Quality of Care | Correction Date |
|---|---|---|---|---|
| CONSTRUCTION TYPE | | | | July 28, 2010 |
| GENERATORS INSPECTED/TESTED | | | | July 28, 2010 |
| VENTILATING EQUIPMENT | | | | July 28, 2010 |
| EXIT LIGHTING | | | | July 28, 2010 |
| SPRINKLER SYSTEM MAINTENANCE | | | | July 28, 2010 |
| STAIRWAY ENCLOSURES AND VERTICAL SHAFTS | | | | July 28, 2010 |
Note: If the latest survey included in this report is more than 12 months old, the Department of Health may have recently surveyed this nursing home or is currently inspecting this home.
If you have questions about the current quality of service delivery at the nursing home, you should contact the facility and request a copy of the latest survey inspection report. The facility is required to post the report in a public area of the nursing home. If you request the report and the nursing home refuses to provide it, please call the New York State Nursing Home Complaint hotline at 1-888-201-4563.