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Deficiency Records for West Roxbury Health and Rehabilitation Center
A list of the most recent deficiencies for West Roxbury Health and Rehabilitation 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 West Roxbury Health and Rehabilitation 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? |
|---|---|---|---|---|
| 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 | 2024-08-27 | 2024-09-06 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-06-10 | 2024-07-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-06-10 | 2024-07-27 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-06-10 | 2024-07-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-21 | 2024-06-05 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-29 | 2023-12-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-29 | 2023-12-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-29 | 2023-12-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-29 | 2023-12-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-07 | 2023-12-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-07 | 2023-12-16 | 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 | 2023-11-07 | 2023-12-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-07 | 2023-12-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-07 | 2023-12-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-07 | 2023-12-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-07 | 2023-12-16 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-07 | 2023-12-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-07 | 2023-12-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-07 | 2023-12-16 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-11-07 | 2023-12-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-07 | 2023-12-16 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-07 | 2023-12-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-07 | 2023-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-29 | 2023-12-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-10 | 2022-12-17 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-11-10 | 2022-12-17 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-11-10 | 2022-12-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-11-10 | 2022-12-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-10 | 2022-12-17 | 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 | 2022-11-10 | 2022-12-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-10 | 2022-12-17 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-10 | 2022-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-10 | 2022-12-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-12-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-10 | 2022-12-17 | 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 | 2022-11-10 | 2022-12-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-11-10 | 2022-12-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-10 | 2022-12-17 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-11-10 | 2022-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-10 | 2022-12-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-14 | 2022-11-22 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-11-14 | 2022-11-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-11-14 | 2022-11-22 | 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 | 2022-11-14 | 2022-11-22 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-11-14 | 2022-11-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-14 | 2022-11-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-03 | 2021-12-22 | 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 | 2021-11-03 | 2021-12-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-03 | 2021-12-22 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-10-15 | 2020-11-16 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-10-15 | 2020-11-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-10-15 | 2020-11-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-15 | 2020-11-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-10-15 | 2020-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-15 | 2020-11-16 | N |
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