A list of the most recent deficiencies for Aperion Care Westchester. 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 | 2023-12-03 | 2023-12-11 | Y |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-06-28 | 2023-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-28 | 2023-08-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-28 | 2023-08-23 | 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 | 2023-06-28 | 2023-07-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-06-28 | 2023-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-15 | 2023-06-30 | N |
| Respond appropriately to all alleged violations. | Health | 2023-01-26 | 2023-02-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-12 | 2023-01-20 | 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 | 2023-01-12 | 2023-01-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-14 | 2022-10-28 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-11 | 2022-10-06 | 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 | 2022-08-11 | 2022-09-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-11 | 2022-09-08 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Use approved construction type or materials. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-11 | 2022-09-02 | 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 | 2022-08-11 | 2022-09-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2022-08-11 | 2022-09-02 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-08-04 | 2022-08-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-04 | 2022-08-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-04 | 2022-08-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-04 | 2022-08-25 | 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 | 2022-08-04 | 2022-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-04 | 2022-08-25 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-04 | 2022-08-25 | 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 | 2022-08-04 | 2022-08-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-08-04 | 2022-08-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-05 | 2022-07-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-24 | 2022-04-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-24 | 2022-04-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-24 | 2022-04-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-24 | 2022-04-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-24 | 2022-04-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-22 | 2022-04-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-22 | 2022-04-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-22 | 2022-04-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-22 | 2022-04-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-22 | 2022-04-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-20 | 2022-04-13 | 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 | 2022-02-22 | 2022-03-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-22 | 2022-03-14 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-02-22 | 2022-03-14 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-22 | 2022-03-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-30 | 2022-02-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-30 | 2022-02-18 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-24 | 2021-12-30 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-08-24 | 2021-12-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-14 | 2021-10-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-14 | 2021-10-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-14 | 2021-10-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-14 | 2021-10-28 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-10-14 | 2021-10-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-14 | 2021-10-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-14 | 2021-10-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-15 | 2021-09-24 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-24 | 2021-09-20 | 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 | 2021-08-24 | 2021-09-20 | 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 | 2021-08-24 | 2021-09-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-24 | 2021-09-20 | 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 | 2021-08-24 | 2021-09-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2021-08-24 | 2021-09-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-26 | 2021-09-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-26 | 2021-09-16 | 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 | 2021-08-26 | 2021-09-16 | 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 | 2021-08-26 | 2021-09-16 | 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 | 2021-08-26 | 2021-09-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-08-26 | 2021-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-26 | 2021-09-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-08-26 | 2021-09-16 | 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 | 2021-08-26 | 2021-09-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-02 | 2021-08-20 | 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 | 2021-08-02 | 2021-08-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-02 | 2021-08-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-17 | 2021-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-17 | 2021-07-12 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-06-17 | 2021-07-12 | Y |
