A list of the most recent deficiencies for Culver West Health 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-27 | 2024-01-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-27 | 2024-01-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-27 | 2024-01-11 | Y |
| 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 | 2023-12-27 | 2024-01-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-15 | 2023-10-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-15 | 2023-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-15 | 2023-10-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-15 | 2023-10-30 | Y |
| 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 | 2023-09-15 | 2023-10-30 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-15 | 2023-10-30 | 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 | 2023-09-20 | 2023-10-18 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-03-24 | 2023-03-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-24 | 2023-02-01 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-12-20 | 2022-12-29 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-11-23 | 2022-11-30 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-10-11 | 2022-11-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-08 | 2022-08-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-08 | 2022-08-05 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-16 | 2022-05-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-09 | 2022-05-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-04 | 2022-04-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-28 | 2021-12-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-28 | 2021-12-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-10-28 | 2021-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-28 | 2021-12-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-28 | 2021-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-28 | 2021-12-01 | 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 | 2021-10-28 | 2021-12-01 | 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 | 2021-10-28 | 2021-12-01 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-10-28 | 2021-12-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-28 | 2021-12-01 | 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 | 2021-10-28 | 2021-12-01 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-10-28 | 2021-12-01 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-10-28 | 2021-12-01 | 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 | 2021-10-28 | 2021-12-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-28 | 2021-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-28 | 2021-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-28 | 2021-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-28 | 2021-11-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-10-28 | 2021-11-24 | 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 | 2021-10-28 | 2021-11-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-28 | 2021-11-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-28 | 2021-11-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-28 | 2021-11-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-28 | 2021-11-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-28 | 2021-11-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-28 | 2021-11-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-08-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-07 | 2021-04-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-28 | 2021-04-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-07 | 2020-02-27 | 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 | 2020-02-07 | 2020-02-27 | 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 | 2020-02-07 | 2020-02-27 | 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 | 2020-02-07 | 2020-02-27 | 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 | 2020-02-07 | 2020-02-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-07 | 2020-02-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-03 | 2020-02-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-02-03 | 2020-02-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-03 | 2020-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-03 | 2020-02-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-03 | 2020-02-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-02-20 | 2019-03-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-02-20 | 2019-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-20 | 2019-03-10 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-02-20 | 2019-03-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-20 | 2019-03-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-20 | 2019-03-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-20 | 2019-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-20 | 2019-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-20 | 2019-03-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-20 | 2019-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-08 | 2019-03-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-02-08 | 2019-03-06 | 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 | 2019-02-08 | 2019-03-06 | 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 | 2019-02-08 | 2019-03-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-08 | 2019-03-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-02-08 | 2019-03-06 | N |
