A list of the most recent deficiencies for Main West Postacute Care. 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-24 | 2023-09-26 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-29 | 2023-09-25 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-08-29 | 2023-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-29 | 2023-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-29 | 2023-09-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-29 | 2023-09-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-29 | 2023-09-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-29 | 2023-09-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-29 | 2023-09-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-08-29 | 2023-09-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-29 | 2023-09-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-25 | 2023-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-25 | 2023-09-22 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-08-25 | 2023-09-22 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-08-25 | 2023-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-25 | 2023-09-22 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-08-25 | 2023-09-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-08-25 | 2023-09-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-04 | 2022-04-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-04 | 2022-04-07 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-02-02 | 2022-02-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-06 | 2022-02-11 | 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 | 2021-08-06 | 2021-10-13 | 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 | 2021-08-06 | 2021-10-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-06 | 2021-10-13 | 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 | 2021-08-06 | 2021-10-13 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-08-06 | 2021-10-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-10-13 | Y |
| Keep all essential equipment working safely. | Health | 2021-08-06 | 2021-10-13 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-08-06 | 2021-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-25 | 2021-08-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-12 | 2020-02-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-12 | 2020-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-12 | 2020-02-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-12-12 | 2020-02-20 | 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 | 2019-12-12 | 2020-02-20 | N |
| 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 | 2019-12-12 | 2020-02-20 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-12-12 | 2020-02-20 | 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 | 2019-12-12 | 2020-02-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-12-12 | 2020-02-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-12 | 2020-02-20 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-12-12 | 2020-02-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-12 | 2020-02-20 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-12-12 | 2020-02-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2020-01-15 | 2020-02-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-17 | 2019-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-17 | 2019-02-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-01-17 | 2019-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-01-17 | 2019-02-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-11 | 2019-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-11 | 2019-02-14 | 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 | 2019-01-11 | 2019-02-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-01-11 | 2019-02-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-11 | 2019-02-14 | 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 | 2019-01-11 | 2019-02-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-01-11 | 2019-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-11 | 2019-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-11 | 2019-02-14 | N |
| Keep all essential equipment working safely. | Health | 2019-01-11 | 2019-02-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-01-11 | 2019-02-14 | N |
