Deficiency Records for Westside Rehab and Care Center

(Home page)

Updated as of March 01, 2024

A list of the most recent deficiencies for Westside Rehab and 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?
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2023-07-13 2023-07-26 Y
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2023-02-07 2023-03-10 N
Establish policies and procedures including evacuation. Fire Safety 2023-02-07 2023-03-10 N
Establish staff and initial training requirements. Fire Safety 2023-02-07 2023-03-10 N
Conduct testing and exercise requirements. Fire Safety 2023-02-07 2023-03-10 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-02-07 2023-03-10 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 2023-02-07 2023-03-10 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-02-07 2023-03-10 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-02-07 2023-03-10 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-02-07 2023-03-10 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-02-07 2023-03-10 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-02-10 2023-03-06 N
Honor the resident's right to manage his or her financial affairs. Health 2023-02-10 2023-03-06 N
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2023-02-10 2023-03-06 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2023-02-10 2023-03-06 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 2023-02-10 2023-03-06 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2023-02-10 2023-03-06 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2023-02-10 2023-03-06 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-02-10 2023-03-06 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2023-02-10 2023-03-06 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-02-10 2023-03-06 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-02-10 2023-03-06 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-02-22 2023-03-06 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2023-02-22 2023-03-05 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 2022-11-30 2022-12-20 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-11-30 2022-12-20 Y
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 2022-11-30 2022-12-20 Y
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Health 2022-11-30 2022-12-20 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2022-08-16 2022-08-26 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 2022-04-08 2022-06-06 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-04-08 2022-06-06 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2022-04-08 2022-06-06 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 2022-04-07 2022-06-06 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-04-07 2022-06-06 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2022-04-07 2022-06-06 N
Provide and implement an infection prevention and control program. Health 2022-04-07 2022-06-06 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 2022-04-08 2022-05-05 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-04-08 2022-05-05 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-04-08 2022-05-05 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-04-08 2022-05-05 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 2022-04-08 2022-05-05 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-04-08 2022-05-05 Y
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2022-04-07 2022-05-05 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-04-07 2022-05-05 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-04-07 2022-05-05 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-04-07 2022-05-05 N
Respond appropriately to all alleged violations. Health 2022-04-07 2022-05-05 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 2022-04-07 2022-05-05 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-04-07 2022-05-05 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-04-07 2022-05-05 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-04-07 2022-05-05 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 2022-04-07 2022-05-05 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2022-04-07 2022-05-05 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2022-04-07 2022-05-05 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 2022-04-07 2022-05-05 N
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2022-04-07 2022-05-05 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-04-07 2022-05-05 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-04-07 2022-05-05 N
Implement a program that monitors antibiotic use. Health 2022-04-07 2022-05-05 N
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2022-04-07 2022-05-05 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-03-29 2022-04-28 N
Create arrangements with other facilities to receive patients. Fire Safety 2022-03-29 2022-04-28 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2022-03-29 2022-04-28 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-03-29 2022-04-28 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-03-29 2022-04-28 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-03-29 2022-04-28 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-03-29 2022-04-28 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2021-10-25 2021-10-28 Y
Ensure that residents are free from significant medication errors. Health 2021-09-23 2021-10-07 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-02-26 2021-04-02 N
Reasonably accommodate the needs and preferences of each resident. Health 2021-02-26 2021-03-18 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 2021-02-26 2021-03-18 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-02-26 2021-03-18 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-02-26 2021-03-18 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-02-26 2021-03-18 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-02-26 2021-03-18 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 2021-02-26 2021-03-18 N
Provide and implement an infection prevention and control program. Health 2021-02-26 2021-03-18 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2021-02-26 2021-03-18 N
Install proper backup exit lighting. Fire Safety 2021-02-24 2021-03-11 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2021-02-24 2021-03-11 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 2021-02-24 2021-03-11 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-02-24 2021-03-11 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-02-24 2021-03-11 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2021-02-24 2021-03-11 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-02-24 2021-03-11 N