A list of the most recent deficiencies for Mid-Wilshire Health Care Cntr. 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? |
|---|---|---|---|---|
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-01-12 | 2024-02-02 | 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 | 2024-01-12 | 2024-02-02 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-12 | 2024-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-01 | 2023-09-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-19 | 2023-06-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-19 | 2023-06-18 | 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 | 2023-05-19 | 2023-06-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-19 | 2023-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-19 | 2023-06-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-18 | 2023-06-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-19 | 2023-06-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-18 | 2023-06-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-18 | 2023-06-12 | 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 | 2023-05-18 | 2023-06-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-18 | 2023-06-12 | 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 | 2023-05-18 | 2023-06-12 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-18 | 2023-06-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-19 | 2023-06-09 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-05-19 | 2023-06-09 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-19 | 2023-06-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-19 | 2023-06-09 | N |
| Post nurse staffing information every day. | Health | 2023-05-19 | 2023-06-09 | 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 | 2023-05-19 | 2023-06-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-19 | 2023-06-09 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-05-19 | 2023-06-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-19 | 2023-06-09 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-05-19 | 2023-06-09 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-19 | 2023-06-09 | N |
| 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 | 2023-05-03 | 2023-05-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-05 | 2022-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-09 | 2022-07-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-12 | 2022-05-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-21 | 2022-05-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-08 | 2021-12-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-23 | 2021-12-06 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-11-23 | 2021-12-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-11 | 2021-09-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-05 | 2021-04-15 | Y |
| 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 | 2019-04-04 | 2019-05-02 | N |
| Post nurse staffing information every day. | Health | 2019-04-04 | 2019-05-02 | 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 | 2019-04-04 | 2019-05-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-04 | 2019-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-04 | 2019-05-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-09 | 2019-04-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-09 | 2019-04-29 | 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 | 2019-04-09 | 2019-04-29 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-04-09 | 2019-04-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-09 | 2019-04-29 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-04-09 | 2019-04-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-09 | 2019-04-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-09 | 2019-04-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Develop a communication plan. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Establish methods for sharing information. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-29 | 2018-05-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-28 | 2018-05-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-28 | 2018-05-16 | 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 | 2018-04-28 | 2018-05-16 | 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 | 2018-04-28 | 2018-05-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-28 | 2018-05-16 | N |
