A list of the most recent deficiencies for Westpark A Waters Community. 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2023-04-03 | 2023-04-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-03 | 2023-04-19 | 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 | 2023-04-03 | 2023-04-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-03 | 2023-04-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-03 | 2023-04-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-03 | 2023-04-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-03 | 2023-04-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-04-03 | 2023-04-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-03 | 2023-04-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-03 | 2023-04-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-27 | 2023-03-20 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-02-27 | 2023-03-20 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-02-27 | 2023-03-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-27 | 2023-03-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-27 | 2023-03-20 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-10-20 | 2022-11-25 | N |
| Meet other general requirements. | Fire Safety | 2022-10-20 | 2022-11-25 | 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 | 2022-10-20 | 2022-11-25 | 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 | 2022-10-20 | 2022-11-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-20 | 2022-11-25 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-10-20 | 2022-11-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-20 | 2022-11-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-20 | 2022-11-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-20 | 2022-11-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-20 | 2022-11-25 | N |
| Provide activities to meet all resident's needs. | Health | 2022-09-14 | 2022-10-02 | 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 | 2022-09-14 | 2022-10-02 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-09-14 | 2022-10-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-10-02 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-07-13 | 2022-07-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-13 | 2022-07-13 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-04-13 | 2022-05-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-04-13 | 2022-05-26 | 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 | 2022-04-13 | 2022-05-26 | 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 | 2022-04-13 | 2022-05-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-13 | 2022-05-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-13 | 2022-05-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-13 | 2022-05-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-13 | 2022-05-26 | 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 | 2022-04-01 | 2022-05-13 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-01 | 2022-05-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-01 | 2022-04-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-04-01 | 2022-04-24 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-01 | 2022-04-24 | N |
| 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 | 2022-04-01 | 2022-04-24 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-04-01 | 2022-04-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-01 | 2022-04-24 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-04-01 | 2022-04-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-01 | 2022-04-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-01 | 2022-04-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-01 | 2022-04-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-01 | 2022-04-24 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-04-01 | 2022-04-24 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-04-01 | 2022-04-24 | 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 | 2022-04-01 | 2022-04-24 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-04-01 | 2022-04-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-01 | 2022-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-01 | 2022-04-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-04-01 | 2022-04-24 | N |
| Report COVID19 data to residents and families. | Health | 2022-04-01 | 2022-04-24 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-01 | 2022-04-24 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-04-01 | 2022-04-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-01 | 2022-04-24 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-04-01 | 2022-04-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-01 | 2022-04-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-01 | 2022-04-24 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-01 | 2022-04-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-01 | 2022-04-24 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-01-27 | 2022-02-17 | 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 | 2022-01-27 | 2022-02-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-27 | 2022-02-17 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-01-27 | 2022-02-17 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-01-27 | 2022-02-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-27 | 2022-02-17 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-10-13 | 2021-10-19 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-13 | 2021-10-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-13 | 2021-10-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-13 | 2021-10-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-13 | 2021-10-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-13 | 2021-10-19 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-10-13 | 2021-10-19 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-10-13 | 2021-10-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-13 | 2021-10-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-13 | 2021-10-05 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-09-13 | 2021-10-05 | N |
