A list of the most recent deficiencies for Westminster Village Kentuckiana. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-30 | 2023-11-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-30 | 2023-11-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-30 | 2023-11-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-30 | 2023-11-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-30 | 2023-11-17 | N |
| Keep all essential equipment working safely. | Health | 2023-10-30 | 2023-11-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Develop a communication plan. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-07 | 2022-12-08 | 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 | 2022-11-07 | 2022-12-08 | 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 | 2022-11-07 | 2022-12-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-07 | 2022-12-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-25 | 2022-11-14 | 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 | 2022-10-25 | 2022-11-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-25 | 2022-11-14 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-10-25 | 2022-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-25 | 2022-11-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-25 | 2022-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-30 | 2022-10-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-22 | 2021-11-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-22 | 2021-11-09 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Develop a communication plan. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-13 | 2021-10-31 | 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 | 2021-09-13 | 2021-10-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-13 | 2021-10-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-17 | 2021-09-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-17 | 2021-09-09 | 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 | 2021-08-17 | 2021-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-17 | 2021-09-09 | N |
