Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Gables Health Care Center during CMS and state inspections, most recent first.
Surveyors found that emergency bathroom call-light cords were missing or improperly positioned in several rooms, with some cords absent entirely and others stretched across bathroom doorways. Staff and maintenance confirmed the deficiencies, and the DON was unaware of the issue until the survey. Facility policy requires accessible call systems in all bathrooms, but this was not met in the affected rooms.
Kitchen staff failed to follow the facility's food service hygiene policy when a Cook was observed in the kitchen with visible facial hair while wearing only a mask and hat instead of a beard net. The Cook stated he avoided the beard restraint due to an allergy and asthma episodes, and the Kitchen Director and Administrator said a mask was acceptable if it covered the beard. The facility policy required beard restraints for food service personnel.
Water was observed dripping from ceiling vents and causing stains, wet floors, and sagging ceiling tiles on the 4th floor, with yellow bins placed in hallways and near the nurse’s station to catch the water. Staff reported the condensation and dripping had been occurring for weeks to months in hallways, a resident room, the kitchen tray line, and the dining area, and that vents were being wiped while buckets and cones were used under affected areas. The DON, Maintenance Director, and Plant Ops Director all acknowledged the ongoing condensation and dripping linked to humidity, rain, and elevator shaft air exchange.
A resident was discharged home, but the MDS incorrectly indicated a discharge to a short-term general hospital. The resident's care plan and discharge summary confirmed the discharge to home, and the resident was cognitively intact. The MDS Coordinator acknowledged the error and stated it would be corrected.
The facility failed to revise a PASRR for a resident with a documented psychotic disorder. Despite medical records and MDS indicating the condition, the PASRR was not updated, leading to a deficiency noted by surveyors.
Emergency Bathroom Call-Light Systems Not Maintained or Accessible
Penalty
Summary
Surveyors identified that the facility failed to ensure emergency bathroom call-light systems were properly installed, maintained, and accessible in several rooms on the 4th floor. Specifically, observations revealed missing shower call-light cords in multiple bathrooms and a missing toilet-side emergency call-light cord in one room. In another instance, a shower call-light cord was found stretched across the bathroom doorway from the shower side to the toilet side. Staff interviews confirmed that the call-light cord had been moved, but the CNA was unaware of the reason for its placement. The Maintenance Director confirmed that the toilet call-light cord had been ripped off and additional rooms were missing shower call-light cords, requiring immediate repair. The DON was not aware of the missing or damaged call-light cords until the survey and acknowledged that these conditions were hazardous. The facility's policy requires that the call system be accessible to residents in each toilet, bath, or shower facility, including when a resident is lying on the floor. At the time of the survey, fifty-four residents resided in the facility, and the deficient practice was observed in three rooms out of sixty on the 4th floor.
Kitchen Staff Did Not Consistently Wear Required Beard Restraint
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when kitchen staff did not consistently wear a beard restraint while assisting with food services. The facility policy titled Food and Nutrition, revised 1/1/2021, required food service personnel to wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that cover all hair, including body hair. During the kitchen tour, Staff A (Cook) was observed pushing a cart in the kitchen wearing a surgical mask and a hat, with parts of his beard visible. When asked about the beard net, he stated that he did not wear one because it made him allergic, then walked to the back of the kitchen, removed his mask, and put on a beard net. The Kitchen Director stated that anyone entering the kitchen was required to wear a hairnet or beard net, and that wearing a mask instead of a beard net was acceptable. Staff A stated he had received in-service about wearing hairnets and beard nets and that the purpose was to prevent contamination of food and possible infection transmission. He also stated he had reported an allergy to the beard restraint and had been told by a previous supervisor that it was fine to wear a mask as long as his mouth and beard were covered. Later, the Kitchen Director and the Administrator both stated that it was okay for Staff A to wear a mask to prevent hair from falling into the food. The Registered Dietician stated that before entering the kitchen, hair nets, hats, beard guards, and hand sanitizing were required.
Water Intrusion and Condensation in Hallways, Dining, and Kitchen Areas
Penalty
Summary
The facility failed to ensure a safe, homelike environment when water was observed dripping from the ceiling and vents on the fourth floor in Wing A and Wing D, with large yellow bins placed in the hallway and near the nurse’s station to catch the water. Surveyors observed water on the floor near the bins, dark brown water stains on ceiling tiles near the elevator and in the North hallway, and a sagging ceiling tile with a security camera that was not in place correctly. Additional observations showed water droplets on the ceiling in Wing B, water damage and a black substance around the edges of air vents, and ceiling tiles that had been replaced but were already developing new watermarks. Interviews with staff showed the dripping had been occurring for some time and had been noticed in multiple areas, including hallways, a resident room, the kitchen tray line, and the dining area. The Kitchen Director stated condensation had been forming and dropping onto the tray line more that week due to rain, and that staff had been wiping the vent with cloth while keeping the tray line in the same position until maintenance moved the vent. The Registered Dietician stated she had observed condensation on vents and that employees wipe the vents. An LPN stated dripping from vents had been noticed in July in hallways and a resident room when it rains and had been reported to Maintenance or Administration. The Environmental Service Supervisor stated she checked the fourth floor three times a day and had noticed condensation and dripping from vents in the hallways the prior week, reporting it to the Plant of Operation, but she did not log the vent observation and cleaning. The Director of Plant Operations stated the condensation was caused by high humidity and air exchange, and that the elevator shafts were contributing to hot air being brought to each floor. The Maintenance Director stated he first noticed condensation and dripping from vents in the hallways about one to two months earlier, placed buckets and cones under affected vents, and replaced the ceiling tile near the front elevator due to condensation. The Administrator stated he did frequent rounds with Maintenance and that condensation varied depending on weather and elevator use.
MDS Coding Error for Discharged Resident
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident who was discharged. Specifically, a resident was discharged home, but the MDS incorrectly indicated that the resident was discharged to a short-term general hospital. The resident had been admitted to the facility for short-term skilled rehabilitation and had a care plan indicating a discharge to home with supportive care services. The discharge summary and progress notes confirmed the resident was discharged home, and the resident was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. The MDS Coordinator acknowledged the coding error during an interview and stated it would be corrected immediately.
Failure to Revise PASRR for Resident with Psychotic Disorder
Penalty
Summary
The facility failed to ensure a level one Pre-Admission Screening and Resident Review (PASRR) was revised following admission for one resident out of 17 sampled residents. Resident #7's most recent Level I PASRR dated 11/15/2022 did not indicate a diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID). However, subsequent medical records and Minimum Data Sets (MDS) documented that the resident had a psychotic disorder, which was not reflected in the PASRR. The Social Services Director (SSD) acknowledged that the resident was not coded for a psychotic disorder at the time of the PASRR completion but was later found to have an active diagnosis of a psychotic disorder based on physician documentation dated 1/9/2024. The deficiency was identified during multiple observations and record reviews from 04/29/2024 to 05/02/2024. The SSD and Director of Nursing (DON) provided documentation confirming the resident's psychotic disorder diagnosis, which was not updated in the PASRR. The facility's policies and procedures require all new admissions and readmissions to be screened for mental disorders, but this was not adequately followed for Resident #7, leading to the deficiency noted by the surveyors.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palmetto Subacute Care Center | 1.1 mi | ★★★★★ | 5 | 0 |
| Coral Gables Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Riviera Health Resort | 3.6 mi | ★★★★★ | 1 | 0 |
| Floridean Health & Rehabilitation Center | 4.6 mi | ★★★★★ | 4 | 0 |
| Harmony Health Center | 4.7 mi | ★★★★★ | 0 | 0 |
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