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Deficiency Records for Western Hills Healthcare Residence
A list of the most recent deficiencies for Western Hills Healthcare Residence. 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 Healthcare Residence. 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 special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-23 | 2024-05-09 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2024-03-23 | 2024-05-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-23 | 2024-05-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-23 | 2024-05-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-23 | 2024-05-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-23 | 2024-05-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-03-23 | 2024-05-09 | 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 | 2024-03-25 | 2024-04-17 | Y |
| 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 | 2024-03-25 | 2024-04-17 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-03-25 | 2024-04-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-25 | 2024-04-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-25 | 2024-04-15 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-03-25 | 2024-04-15 | Y |
| 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 | 2024-03-25 | 2024-04-15 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-03-25 | 2024-04-15 | 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 | 2024-03-25 | 2024-04-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-25 | 2024-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-25 | 2024-04-15 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-23 | 2024-04-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-25 | 2024-04-12 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-03-25 | 2024-04-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-25 | 2024-04-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-03-25 | 2024-03-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-25 | 2024-03-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-08 | 2023-03-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-08 | 2023-03-09 | Y |
| 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 | 2023-02-08 | 2023-03-09 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-02-08 | 2023-03-09 | Y |
| 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 | 2023-02-08 | 2023-03-09 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-02-08 | 2023-03-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-08 | 2023-03-09 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-09 | 2023-03-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-10 | 2022-05-31 | Y |
| 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 | 2021-11-11 | 2021-12-24 | Y |
| Ensure resident rooms meet each resident's needs. | Health | 2021-11-11 | 2021-12-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-11 | 2021-12-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-11 | 2021-12-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-11 | 2021-12-11 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-11-11 | 2021-12-11 | 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 | 2021-11-11 | 2021-12-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-11 | 2021-12-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-11 | 2021-12-11 | N |
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