A list of the most recent deficiencies for Westlake Convalescent Hospital. 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 appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-04 | 2023-10-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-02 | 2023-03-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-02 | 2023-03-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-01 | 2022-04-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-04-01 | 2022-04-27 | 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 | 2022-04-01 | 2022-04-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-04-01 | 2022-04-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-01 | 2022-04-27 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-04-01 | 2022-04-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-01 | 2022-04-27 | 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 | 2022-04-01 | 2022-04-27 | 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 | 2022-04-01 | 2022-04-27 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-04-01 | 2022-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-01 | 2022-04-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-01 | 2022-04-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-04 | 2022-04-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-04-04 | 2022-04-15 | 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 | 2022-04-04 | 2022-04-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-04 | 2022-04-15 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-04-04 | 2022-04-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-04 | 2022-04-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-04 | 2022-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-04 | 2022-04-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-04 | 2022-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-25 | 2022-03-04 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-10 | 2022-01-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-01 | 2021-09-10 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-04-18 | 2019-06-03 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-04-18 | 2019-06-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-18 | 2019-06-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-18 | 2019-06-03 | N |
| Provide appropriate foot care. | Health | 2019-04-18 | 2019-06-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-18 | 2019-06-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-04-18 | 2019-06-03 | 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 | 2019-04-18 | 2019-06-03 | 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 | 2019-04-18 | 2019-06-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-18 | 2019-06-03 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-18 | 2019-06-03 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-04-16 | 2019-06-03 | 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 | 2019-04-16 | 2019-06-03 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-04-16 | 2019-06-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-04-16 | 2019-06-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-04-16 | 2019-06-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-16 | 2019-06-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-16 | 2019-06-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-04-16 | 2019-06-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-16 | 2019-06-03 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-04-16 | 2019-06-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-16 | 2019-06-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-16 | 2019-06-03 | N |
| Develop a communication plan. | Fire Safety | 2018-04-20 | 2018-05-23 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-04-20 | 2018-05-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-04-20 | 2018-05-23 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-04-20 | 2018-05-23 | 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 | 2018-04-20 | 2018-05-23 | 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 | 2018-04-20 | 2018-05-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-04-20 | 2018-05-23 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2018-04-20 | 2018-05-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-04-16 | 2018-05-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-16 | 2018-05-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-16 | 2018-05-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-04-16 | 2018-05-15 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-04-16 | 2018-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-04-16 | 2018-05-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-04-16 | 2018-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-16 | 2018-05-15 | 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 | 2018-04-16 | 2018-05-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-04-16 | 2018-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-16 | 2018-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-16 | 2018-05-15 | N |
