A list of the most recent deficiencies for Westy Community Care Home. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-10 | 2023-10-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-28 | 2023-05-19 | N |
| Respond appropriately to all alleged violations. | Health | 2023-03-28 | 2023-05-19 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-03-28 | 2023-05-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-28 | 2023-05-19 | 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 | 2023-03-28 | 2023-05-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-06 | 2023-05-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-06 | 2023-05-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-06 | 2023-05-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-06 | 2023-05-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-06 | 2023-05-04 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-04-06 | 2023-05-04 | 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 | 2023-03-28 | 2023-04-19 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-03-28 | 2023-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-28 | 2023-04-19 | 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 | 2023-03-28 | 2023-04-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-03-28 | 2023-04-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-13 | 2023-02-24 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Use approved construction type or materials. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-06 | 2021-10-20 | 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 | 2021-10-06 | 2021-10-20 | 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 | 2021-10-06 | 2021-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-06 | 2021-10-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-09-08 | 2021-09-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-08 | 2021-09-10 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-19 | 2019-08-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-11 | 2019-08-14 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-07-11 | 2019-08-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-07-11 | 2019-08-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-11 | 2019-08-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-11 | 2019-08-14 | 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 | 2019-07-11 | 2019-08-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-11 | 2019-08-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-11 | 2019-08-14 | 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 | 2019-07-11 | 2019-08-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-07-11 | 2019-08-14 | 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 | 2019-07-11 | 2019-08-14 | 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 | 2019-07-11 | 2019-08-14 | 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 | 2019-07-11 | 2019-08-14 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-07-11 | 2019-08-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-07-11 | 2019-08-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-11 | 2019-08-14 | N |
