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Deficiency Records for The Westchester House
A list of the most recent deficiencies for The Westchester House. 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 The Westchester House. 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 the wrongful use of the resident's belongings or money. | Health | 2024-03-01 | 2024-04-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-01 | 2024-04-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-03 | 2023-08-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-03 | 2023-08-03 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-15 | 2023-07-28 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-06-15 | 2023-07-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-15 | 2023-07-28 | 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 | 2023-06-15 | 2023-07-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-15 | 2023-07-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-15 | 2023-07-28 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-06-15 | 2023-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-15 | 2023-07-28 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2023-06-15 | 2023-07-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-15 | 2023-07-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-15 | 2023-07-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-15 | 2023-07-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-15 | 2023-07-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-15 | 2023-07-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-15 | 2023-07-28 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Use approved construction type or materials. | Fire Safety | 2023-06-15 | 2023-07-28 | 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 | 2023-06-15 | 2023-07-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-15 | 2023-07-28 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-03-08 | 2023-04-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-08 | 2023-04-12 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-12-30 | 2023-04-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-30 | 2023-04-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-08 | 2023-04-04 | 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 | 2023-03-08 | 2023-04-04 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-08 | 2023-04-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-08 | 2023-04-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-08 | 2023-04-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-08 | 2023-04-04 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-03-08 | 2023-04-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-08 | 2023-04-04 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-03-08 | 2023-04-04 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-12-30 | 2023-04-04 | 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 | 2022-12-30 | 2023-04-04 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-12-30 | 2023-04-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-30 | 2023-04-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-30 | 2023-04-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-30 | 2023-04-04 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-12-30 | 2023-04-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-30 | 2023-04-04 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-30 | 2023-04-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-30 | 2023-02-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-21 | 2022-04-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-21 | 2022-04-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-21 | 2022-04-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-07 | 2022-04-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-07 | 2022-04-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-07 | 2022-04-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-07 | 2022-03-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-11 | 2019-11-27 | 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 | 2019-10-11 | 2019-11-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-11 | 2019-11-20 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-10-11 | 2019-11-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-11 | 2019-11-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-11 | 2019-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-11 | 2019-11-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-11 | 2019-11-20 | 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 | 2019-10-11 | 2019-11-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-11 | 2019-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-11 | 2019-11-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-08-22 | 2018-09-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-08-22 | 2018-09-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-22 | 2018-09-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-22 | 2018-09-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-22 | 2018-09-26 | 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 | 2018-08-22 | 2018-09-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-22 | 2018-09-26 | N |
| Dispose of garbage and refuse properly. | Health | 2018-08-22 | 2018-09-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-22 | 2018-09-26 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2018-08-22 | 2018-09-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-22 | 2018-09-26 | N |
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