Deficiency Records for Westview of Derby Rehabilitation and Health Care Cen
Updated as of March 01, 2024
A list of the most recent deficiencies for Westview of Derby Rehabilitation and Health Care Cen. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-26 | 2023-09-26 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-05-17 | 2023-08-01 | 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 | 2023-05-17 | 2023-08-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-17 | 2023-08-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-18 | 2023-07-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-18 | 2023-07-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-18 | 2023-07-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-18 | 2023-07-01 | 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 | 2023-05-18 | 2023-07-01 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-18 | 2023-07-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-18 | 2023-07-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-18 | 2023-07-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-18 | 2023-07-01 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-18 | 2023-07-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-18 | 2023-07-01 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-05-18 | 2023-07-01 | Y |
| Meet other general requirements that are deficient. | Fire Safety | 2023-05-17 | 2023-05-17 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-01-11 | 2023-02-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-11 | 2023-02-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-11 | 2022-09-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-30 | 2021-11-14 | 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 | 2021-09-30 | 2021-11-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-30 | 2021-11-14 | 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 | 2021-09-30 | 2021-11-14 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-09-30 | 2021-11-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-30 | 2021-11-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-30 | 2021-11-14 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-09-30 | 2021-11-14 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-09-30 | 2021-11-14 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-09-30 | 2021-11-14 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-30 | 2021-11-14 | Y |
| 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 | 2021-09-30 | 2021-11-14 | Y |
| 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 | 2021-09-30 | 2021-11-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-30 | 2021-11-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-30 | 2021-11-14 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-09-30 | 2021-11-14 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-13 | 2021-11-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-13 | 2021-11-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-13 | 2021-11-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-13 | 2021-11-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-13 | 2021-11-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-13 | 2021-11-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-13 | 2021-11-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-12-03 | 2019-12-27 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-09 | 2019-10-08 | 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 | 2019-09-09 | 2019-10-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-09 | 2019-10-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-13 | Not Fixed | N |
