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Deficiency Records for Westy Community Care Home
A list of the most recent deficiencies for Westy Community Care Home. 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 Westy Community Care Home. 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? |
|---|---|---|---|---|
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-14 | 2024-10-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-10-14 | 2024-10-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-09-18 | 2024-09-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-09-18 | 2024-09-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-09-18 | 2024-09-27 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-09-18 | 2024-09-27 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-09-18 | 2024-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-18 | 2024-09-27 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-09-18 | 2024-09-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-09-18 | 2024-09-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-26 | 2024-03-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-26 | 2024-03-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-31 | 2024-01-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-10 | 2023-10-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-28 | 2023-05-19 | N |
| Respond appropriately to all alleged violations. | Health | 2023-03-28 | 2023-05-19 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-03-28 | 2023-05-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-28 | 2023-05-19 | 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 | 2023-03-28 | 2023-05-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-06 | 2023-05-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-06 | 2023-05-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-06 | 2023-05-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-06 | 2023-05-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-06 | 2023-05-04 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-04-06 | 2023-05-04 | 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 | 2023-03-28 | 2023-04-19 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-03-28 | 2023-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-28 | 2023-04-19 | 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 | 2023-03-28 | 2023-04-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-03-28 | 2023-04-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-13 | 2023-02-24 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Use approved construction type or materials. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-10-06 | 2021-10-20 | 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 | 2021-10-06 | 2021-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-09-08 | 2021-09-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-08 | 2021-09-10 | N |
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