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Deficiency Records for Westside Rehab and Care Center
A list of the most recent deficiencies for Westside Rehab and Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Westside Rehab and Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-21 | 2024-06-26 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-05-21 | 2024-05-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-21 | 2024-05-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-05-21 | 2024-05-31 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-05-21 | 2024-05-31 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-03-22 | 2024-05-31 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-03-22 | 2024-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-22 | 2024-05-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-22 | 2024-05-31 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-03-22 | 2024-05-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-04-09 | 2024-04-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-04-09 | 2024-04-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-04-09 | 2024-04-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-04-09 | 2024-04-26 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-04-09 | 2024-04-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-09 | 2024-04-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-04-09 | 2024-04-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-04-09 | 2024-04-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-04-09 | 2024-04-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-09 | 2024-04-26 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-03-22 | 2024-04-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-03-22 | 2024-04-12 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-03-22 | 2024-04-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-22 | 2024-04-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-03-22 | 2024-04-12 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-13 | 2023-07-26 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-07 | 2023-03-10 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-22 | 2023-03-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-10 | 2023-03-06 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-02-10 | 2023-03-06 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-02-10 | 2023-03-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-10 | 2023-03-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-10 | 2023-03-06 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-02-10 | 2023-03-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-02-10 | 2023-03-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-10 | 2023-03-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-10 | 2023-03-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-10 | 2023-03-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-10 | 2023-03-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-22 | 2023-03-05 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-11-30 | 2022-12-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-30 | 2022-12-20 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-11-30 | 2022-12-20 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-11-30 | 2022-12-20 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-16 | 2022-08-26 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-08 | 2022-06-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-08 | 2022-06-06 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-08 | 2022-06-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-07 | 2022-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-07 | 2022-06-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-07 | 2022-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-07 | 2022-06-06 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-04-08 | 2022-05-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-08 | 2022-05-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-08 | 2022-05-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-08 | 2022-05-05 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-08 | 2022-05-05 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-08 | 2022-05-05 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-07 | 2022-05-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-07 | 2022-05-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-07 | 2022-05-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-07 | 2022-05-05 | N |
| Respond appropriately to all alleged violations. | Health | 2022-04-07 | 2022-05-05 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-04-07 | 2022-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-07 | 2022-05-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-07 | 2022-05-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-07 | 2022-05-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-07 | 2022-05-05 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-04-07 | 2022-05-05 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-04-07 | 2022-05-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-04-07 | 2022-05-05 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-04-07 | 2022-05-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-05-05 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-04-07 | 2022-05-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-04-07 | 2022-05-05 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-04-07 | 2022-05-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-29 | 2022-04-28 | N |
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