Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Westgate Nursing & Rehabilitation Community during CMS and state inspections, most recent first.
Improper Sink Drain Connections and Soiled Food Service Equipment: Surveyors observed that the drain line from the 3-compartment sink extended into the bowl drain, creating an improper air gap, and both the drain line and receiving bowl drain had excess food debris. The CDM stated the sink was used to wash, rinse, and sanitize dirty utensils not sent through the dish machine. Surveyors also found the vegetable wash sink and the ice machine drain line were connected into the same bowl drain, while the vegetable wash sink was used to wash vegetables before food prep.
Medication carts were found with unattended and loose meds, debris, and spilled medication material in both the South and North carts. An LPN left an Aspirin tablet unattended on top of the cart, and multiple loose tablets/capsules were later observed in the drawers of both carts. The DON stated meds are not to be left unattended and carts are to be cleaned regularly, while an RN said night shift had been asked to clean both carts but there was no official check-off sheet showing it was done.
Therapeutic diet orders were not followed for two residents with significant medical histories including DM, CHF, CKD, and failure to thrive. One resident ordered no salt added/no sugar added received a tray with a salt packet, and another resident ordered a consistent carbohydrate and 2 g sodium diet received regular sugar packets and a tray card that did not reflect the sodium restriction. Staff were unable to explain the SS notation, and dietary leadership stated the facility did not provide the ordered consistent carb or 2 g sodium diets.
Failure to record tube feeding volume: A resident with esophageal cancer, dysphagia, malnutrition, and a G-tube had a physician order for nighttime enteral feeding, but the EMR lacked documentation of the total amount administered. The record also showed significant weight loss and no shift-to-shift intake documentation, while an RN, an ADON LPN, and the CDM all acknowledged that total tube feed and water volumes were not being recorded.
Failure to use EBP during high-contact care: A resident with paraplegia, COPD, HF, an indwelling urinary catheter, and pressure injuries had EBP signs posted in the room, but CNAs did not wear protective gowns during close-contact care. Observations showed staff providing repositioning, catheter-related care, incontinence care, clothing changes, linen changes, and a total mechanical lift transfer while only using gloves, despite acknowledging that gowns should have been worn.
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.
Improper Sink Drain Connections and Soiled Food Service Equipment
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety. During a kitchen tour with the Certified Dietary Manager on 12/2/2025, surveyors observed that the drain line from the three-compartment sink extended down into the bowl drain, creating an improper air gap. The drain line and the receiving bowl drain were both soiled with excess food debris. The Certified Dietary Manager stated that dirty kitchen utensils that do not go through the dish machine are washed, rinsed, and sanitized in this three-compartment sink. At the same time, surveyors observed that the drain line on the vegetable wash sink was indirectly connected to the bowl drain below it, and the Certified Dietary Manager stated that this sink was used for washing the facility's vegetables before food preparation. Surveyors also noted that the drain line for the facility ice machine, located beside the vegetable wash sink, extended down into the same bowl drain below the vegetable wash sink. The report cited the 2022 FDA Food Code section 5-402.11 regarding backflow prevention and section 4-601.11 regarding cleanliness of equipment, food-contact surfaces, nonfood-contact surfaces, and utensils.
Medication carts contained unattended and loose medications
Penalty
Summary
The facility failed to securely store medications in two of two medication carts reviewed. On 12/3/25 at 6:20 AM, an unattended pill cup containing one chewable Aspirin 81 mg tablet was left on the South medication cart. When asked about it, LPN D stated she made a mistake and should have locked it up or taken it with her when she went to get the doorbell alarm. At 7:00 AM, the South medication cart was observed with debris of paper and medication powder in the second drawer, along with loose gabapentin 300 mg, torsemide 10 mg, valsartan and sacubitril 26 mg/24 mg, and quetiapine fumarate 25 mg tablets/capsules. At 8:20 AM, the North medication cart was observed with paper debris, polyethylene glycol granules, spilled liquid potassium, and multiple loose medications including acetaminophen 325 mg, tamsulosin hydrochloride 0.4 mg, gabapentin 100 mg, metoprolol succinate ER 25 mg, rivaroxaban 10 mg, furosemide 40 mg, quetiapine fumarate 25 mg, sitagliptin 25 mg, levocetirizine dihydrochloride 5 mg, norethindrone acetate 5 mg, and apixaban 5 mg. LPN P stated the carts should have been cleaned the prior night because the night nurses knew surveyors were present. The DON stated medications are not to be left unattended and carts are to be cleaned regularly, and RN E stated night shift had been asked to clean both carts two days earlier but there was no official check-off sheet documenting completion.
Therapeutic Diet Orders Not Followed for Two Residents
Penalty
Summary
The facility failed to ensure that therapeutic diets were correctly prescribed and followed for two residents reviewed for nutritional concerns. Resident #26 was admitted with diagnoses including failure to thrive, DM, HTN, and chronic kidney disease, and the physician ordered a regular texture diet with no salt added, no sugar added, and regular fluids. On 12/03/2025, the breakfast tray observed for R26 included a salt packet even though the tray card indicated a no added salt restriction. Resident #51 was admitted with CHF, chronic kidney disease, and DM, and the physician ordered a regular diet with thin liquids, consistent carbohydrate, and 2 g sodium. The care plan identified nutritional/hydration risk related to CHF and DM and directed diet per doctor’s order. On 12/03/2025, the breakfast tray for R51 included regular sugar packets, salt and pepper, and a tray card showing Regular, SS, but no indication of the ordered sodium restriction. Staff questioned about the SS notation could not explain it, and the CDM stated the facility did not serve a consistent carbohydrate or 2 g sodium diet and used SS and NAS diets under a liberalized diet policy. The RD stated the 2 g sodium diet was not a diet the facility provided and agreed the facility should follow the physician’s orders.
Failure to Record Tube Feeding Volume
Penalty
Summary
The facility failed to monitor and record the amount of tube feeding administered for one resident with a G-tube. The resident was admitted with diagnoses including malignant neoplasm of the esophagus, protein-calorie malnutrition, dysphagia, and failure to thrive, and the admission MDS indicated moderate cognitive impairment. The resident stated he had a history of cancer and used a G-tube for enteral feedings, with nighttime feedings scheduled. A physician order dated 12/1/25 directed a nighttime tube feeding at 150 ml x 10 hours, but no recorded total amount of tube feeding was documented in the electronic medical record to show the resident was tolerating or receiving the prescribed amount. The resident’s record showed significant weight loss after admission, including a drop from 163.4 pounds on 9/23/25 to 147.6 pounds on 11/17/25, and a progress note stated the resident had a new G-tube because he was unable to consume adequate kcal/protein intake since admission. The care plan identified the resident as at risk for complications due to feeding tube use and directed staff to record and monitor intake and output every shift, but intake records from 11/10/25 through 12/3/25 had no shift-to-shift intake documented. During interviews, the unit manager RN stated she had never been required to record the amount and only signed the MAR, the ADON LPN stated there was no documentation of total volume recorded for tube feedings or water, and the CDM stated recording total tube feeding volume would help determine tolerance and whether adjustments were needed.
Failure to Use EBP During High-Contact Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were implemented during high-contact care activities for Resident #6, who had paraplegia, heart failure, COPD, an indwelling urinary catheter, and required substantial to maximal assistance with bed mobility, lower body dressing, and footwear. The resident’s room had signs posted indicating EBP use for high-contact care, including dressing, bathing, transferring, linen changes, hygiene, toileting, and device care. During an observation, a CNA entered the room, performed hand hygiene, donned gloves, unhooked the catheter bag, repositioned the resident’s legs, and leaned over the resident to plug in a phone charger, but did not wear a protective gown during the close-contact care. On another observation, two CNAs provided incontinence care, changed the resident’s shirt, transferred the resident with a total mechanical lift, and removed soiled linens while the resident’s clothing was in direct contact with the resident and bed linens. The EBP sign remained posted behind the bed, but neither CNA wore protective gowns during the observed incontinence care, clothing change, linen change, or transfer. In interview immediately after the observation, both CNAs acknowledged the EBP signs were posted and stated that protective gowns should be worn while providing care to the resident. The resident’s physician orders included targeted gown and glove use during high-contact resident care activities for the foley catheter and bilateral stage 2 pressure injuries to the posterior thighs.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 5 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Westgate Nursing & Rehabilitation Community.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.