A list of the most recent deficiencies for Western Hills Health Care 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-01-05 | 2023-02-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-10 | 2022-12-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-06 | 2022-12-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-06 | 2022-12-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-06 | 2022-12-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-12 | 2022-08-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-12 | 2022-08-01 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-05 | 2021-10-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-05 | 2021-10-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-05 | 2021-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-05 | 2021-09-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-05 | 2021-09-15 | 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 | 2021-08-05 | 2021-09-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-05 | 2021-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-05 | 2021-08-16 | N |
| Use approved construction type or materials. | Fire Safety | 2021-08-05 | 2021-08-13 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-07-13 | 2021-07-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-13 | 2021-07-29 | N |
| Respond appropriately to all alleged violations. | Health | 2021-07-13 | 2021-07-29 | 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 | 2021-07-13 | 2021-07-29 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-07-13 | 2021-07-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-13 | 2021-07-29 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-13 | 2021-07-29 | 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 | 2021-07-13 | 2021-07-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-13 | 2021-07-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-13 | 2021-07-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-13 | 2021-07-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-13 | 2021-07-29 | 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 | 2021-07-13 | 2021-07-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-13 | 2021-07-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-13 | 2021-07-29 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2019-08-08 | 2019-11-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-07-16 | 2019-09-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-08 | 2019-09-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-08 | 2019-08-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-16 | 2019-08-19 | 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 | 2019-07-16 | 2019-08-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-16 | 2019-08-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-16 | 2019-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-16 | 2019-08-19 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-07-16 | 2019-08-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-08 | 2019-08-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-08 | 2019-08-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-08 | 2019-08-08 | N |
