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Deficiency Records for Western Hills Retirement Village
A list of the most recent deficiencies for Western Hills Retirement Village. 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 Western Hills Retirement Village. 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2023-07-11 | 2023-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-04 | 2022-03-14 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-09-21 | 2022-02-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-23 | 2021-12-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-09-23 | 2021-12-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-23 | 2021-12-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-23 | 2021-12-03 | 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 | 2021-09-23 | 2021-12-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-23 | 2021-12-03 | 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 | 2021-09-23 | 2021-12-03 | 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 | 2021-09-23 | 2021-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-23 | 2021-12-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-21 | 2021-12-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-21 | 2021-12-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-21 | 2021-12-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-21 | 2021-12-03 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-26 | 2020-07-31 | 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 | 2020-02-26 | 2020-07-31 | 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 | 2020-02-26 | 2020-07-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-26 | 2020-07-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-26 | 2020-03-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-02-26 | 2020-03-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-26 | 2020-03-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-26 | 2020-03-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-26 | 2020-03-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-26 | 2020-03-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-26 | 2020-03-27 | 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 | 2018-12-13 | 2019-02-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-12-13 | 2019-02-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-13 | 2019-02-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-13 | 2019-02-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-13 | 2019-02-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-13 | 2019-02-05 | 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 | 2018-12-13 | 2019-02-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-12-10 | 2019-02-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-10 | 2019-02-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-12-10 | 2019-02-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-12-10 | 2019-02-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-10 | 2019-02-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-10 | 2019-02-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-10 | 2019-02-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-10 | 2019-02-05 | N |
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