A list of the most recent deficiencies for Westhaven 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? |
|---|---|---|---|---|
| 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 | 2023-03-30 | 2023-04-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-30 | 2023-04-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-30 | 2023-04-25 | 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 | 2023-03-30 | 2023-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-30 | 2023-04-25 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-04-03 | 2023-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-20 | 2022-01-03 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-12-20 | 2021-12-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-20 | 2021-12-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-12-20 | 2021-12-27 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-12-20 | 2021-12-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-20 | 2021-12-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-20 | 2021-12-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-20 | 2021-12-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-20 | 2021-12-20 | N |
| Have an externally vented heating system. | Fire Safety | 2021-12-20 | 2021-12-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-20 | 2021-12-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-06 | 2019-12-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-31 | 2019-11-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-31 | 2019-11-14 | 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 | 2019-10-31 | 2019-11-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-10-31 | 2019-11-14 | 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 | 2019-10-31 | 2019-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-31 | 2019-11-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-11-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-31 | 2019-11-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-06 | 2019-11-12 | N |
