A list of the most recent deficiencies for Westside Retirement Village. 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2024-01-02 | 2024-01-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-01-02 | 2024-01-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-02 | 2024-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-02 | 2024-01-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-02 | 2024-01-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-01-02 | 2024-01-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-02 | 2024-01-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-04 | 2024-01-04 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-04 | 2024-01-04 | 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 | 2023-12-04 | 2024-01-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-04 | 2024-01-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-04 | 2024-01-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-04 | 2024-01-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-04 | 2024-01-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-04 | 2024-01-04 | 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 | 2023-12-04 | 2024-01-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-04 | 2024-01-04 | 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 | 2023-12-04 | 2024-01-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-04 | 2024-01-04 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-12-04 | 2024-01-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-04 | 2024-01-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-12-04 | 2024-01-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-04 | 2024-01-04 | 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 | 2023-12-04 | 2024-01-04 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-12-04 | 2024-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-04 | 2024-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-04 | 2024-01-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-04 | 2024-01-04 | N |
| Keep all essential equipment working safely. | Health | 2023-12-04 | 2024-01-04 | 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 | 2023-12-04 | 2024-01-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-12-04 | 2024-01-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-12 | 2023-11-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-12 | 2023-11-03 | 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 | 2023-10-12 | 2023-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-12 | 2023-11-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-12 | 2023-11-03 | 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 | 2023-04-11 | 2023-04-28 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-05 | 2022-10-23 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-10-05 | 2022-10-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-05 | 2022-10-23 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2022-10-05 | 2022-10-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-01 | 2022-10-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-01 | 2022-10-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-01 | 2022-10-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-01 | 2022-10-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-01 | 2022-10-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-01 | 2022-10-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-01 | 2022-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-01 | 2022-10-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-01 | 2022-10-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-01 | 2022-10-01 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-09-01 | 2022-10-01 | 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 | 2022-09-01 | 2022-10-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-01 | 2022-10-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-01 | 2022-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-01 | 2022-10-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-01 | 2022-10-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-20 | 2022-02-10 | Y |
| 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 | 2021-10-20 | 2021-11-05 | Y |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Ensure gas cylinders are properly stored. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-08-18 | 2021-10-08 | N |
| Meet other general requirements. | Fire Safety | 2021-08-18 | 2021-09-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-06 | 2021-08-30 | 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 | 2021-08-06 | 2021-08-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-06 | 2021-08-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-06 | 2021-08-30 | 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 | 2021-08-06 | 2021-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-06 | 2021-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-06 | 2021-08-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-06 | 2021-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-08-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-04 | 2021-07-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-04 | 2021-07-02 | Y |
