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Deficiency Records for Weston County Health Services
A list of the most recent deficiencies for Weston County Health Services. 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 Weston County Health Services. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-07-09 | 2024-09-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-09 | 2024-09-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-09 | 2024-09-04 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2024-07-09 | 2024-09-04 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-07-11 | 2024-08-25 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-07-11 | 2024-08-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-07-11 | 2024-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-11 | 2024-08-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-13 | 2023-05-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-13 | 2023-05-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-13 | 2023-05-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-13 | 2023-05-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-13 | 2023-05-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-13 | 2023-05-01 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-04-13 | 2023-05-01 | Y |
| 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 | 2023-04-13 | 2023-05-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-13 | 2023-05-01 | 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 | 2023-04-13 | 2023-05-01 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-04-13 | 2023-05-01 | Y |
| 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 | 2023-04-13 | 2023-05-01 | N |
| Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction. | Fire Safety | 2023-04-13 | 2023-05-01 | 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 | 2023-04-13 | 2023-05-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-13 | 2023-05-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-13 | 2023-05-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-13 | 2023-05-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-16 | 2022-07-15 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-06-16 | 2022-07-15 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-03-08 | 2022-05-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-03-08 | 2022-05-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-03-08 | 2022-04-28 | 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 | 2022-03-08 | 2022-04-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-08 | 2022-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-08 | 2022-04-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-08 | 2022-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-08 | 2022-04-28 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-03-10 | 2022-03-31 | N |
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