A list of the most recent deficiencies for Westminster Commons. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-19 | 2024-03-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-19 | 2024-03-04 | N |
| Respond appropriately to all alleged violations. | Health | 2024-01-19 | 2024-03-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-19 | 2024-03-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-19 | 2024-03-04 | 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 | 2024-01-19 | 2024-03-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-19 | 2024-03-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-19 | 2024-03-04 | 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 | 2024-01-19 | 2024-03-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-19 | 2024-03-04 | 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 | 2024-01-19 | 2024-03-04 | 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 | 2024-01-19 | 2024-03-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-19 | 2024-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-23 | 2024-03-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-23 | 2024-03-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-03 | 2022-08-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-03 | 2022-08-01 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-06-03 | 2022-08-01 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-03 | 2022-08-01 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-14 | 2019-02-01 | 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 | 2018-11-17 | 2018-12-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-17 | 2018-12-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-17 | 2018-12-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-17 | 2018-12-26 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2018-11-17 | 2018-12-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-11-17 | 2018-12-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-11-17 | 2018-12-26 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-14 | 2018-12-26 | N |
