Deficiency Records for Westy Community Care Home
Updated as of November 01, 2020
This is not the most recent data for Westy Community Care Home. For the most recent information, click here.
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? |
---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-26 | 2020-02-26 | 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 |
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 |
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 | Y |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-07-11 | 2019-08-14 | Y |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-07-11 | 2019-08-14 | Y |
Ensure each resident receives an accurate assessment. | Health | 2019-07-11 | 2019-08-14 | Y |
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 | 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 | 2019-07-11 | 2019-08-14 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-11 | 2019-08-14 | Y |
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 | Y |
Observe each nurse aide's job performance and give regular training. | Health | 2019-07-11 | 2019-08-14 | 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 | 2019-07-11 | 2019-08-14 | Y |
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 | 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 | 2019-07-11 | 2019-08-14 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-07-11 | 2019-08-14 | Y |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-07-11 | 2019-08-14 | Y |
Provide and implement an infection prevention and control program. | Health | 2019-07-11 | 2019-08-14 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-04 | 2018-11-03 | 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 | 2018-10-04 | 2018-11-03 | Y |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-10-04 | 2018-11-03 | Y |
Ensure each resident receives an accurate assessment. | Health | 2018-10-04 | 2018-11-03 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-04 | 2018-11-03 | 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 | 2018-10-04 | 2018-11-03 | Y |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-04 | 2018-11-03 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-04 | 2018-11-03 | Y |
Provide activities to meet all resident's needs. | Health | 2018-10-04 | 2018-11-03 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-04 | 2018-11-03 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-04 | 2018-11-03 | Y |
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 | 2018-10-04 | 2018-11-03 | Y |
Observe each nurse aide's job performance and give regular training. | Health | 2018-10-04 | 2018-11-03 | 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 | 2018-10-04 | 2018-11-03 | Y |
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 | 2018-10-04 | 2018-11-03 | Y |
Provide or obtain dental services for each resident. | Health | 2018-10-04 | 2018-11-03 | Y |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-10-04 | 2018-11-03 | Y |
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 | 2018-10-04 | 2018-11-03 | Y |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-10-04 | 2018-11-03 | Y |
Provide or obtain dental services for each resident. | Health | 2018-06-05 | 2018-06-11 | Y |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
Address subsistence needs for staff and patients. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
Establish policies and procedures for sheltering. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
Establish policies and procedures for volunteers. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
Provide primary/alternate means for communication. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
Provide family notifications of emergency plan. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
Conduct testing and exercise requirements. | Fire Safety | 2018-04-23 | 2018-05-23 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-14 | 2018-03-30 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-03-14 | 2018-03-30 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-14 | 2018-03-30 | 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 | 2018-03-14 | 2018-03-30 | Y |
Provide enough food/fluids to maintain a resident's health. | Health | 2018-03-14 | 2018-03-30 | Y |
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 | 2018-03-14 | 2018-03-30 | 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 | 2018-03-14 | 2018-03-30 | Y |
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-10-06 | 2017-10-16 | Y |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-06 | 2017-10-16 | Y |
Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home. | Health | 2017-10-06 | 2017-10-16 | Y |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-06 | 2017-10-16 | Y |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-10-06 | 2017-10-16 | Y |
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-03-15 | 2017-05-04 | N |
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-03-15 | 2017-05-04 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-03-15 | 2017-05-04 | N |
Give residents a notice of rights, rules, services and charges. | Health | 2017-03-15 | 2017-03-16 | N |
Try to resolve each resident's complaints quickly. | Health | 2017-03-15 | 2017-03-16 | N |
Provide housekeeping and maintenance services. | Health | 2017-03-15 | 2017-03-16 | N |
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2017-03-15 | 2017-03-16 | N |
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-03-15 | 2017-03-16 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-15 | 2017-03-16 | N |
Ensure residents maintain acceptable nutritional status. | Health | 2017-03-15 | 2017-03-16 | N |
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-03-15 | 2017-03-16 | N |
Store, cook, and serve food in a safe and clean way. | Health | 2017-03-15 | 2017-03-16 | N |
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-03-15 | 2017-03-16 | N |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-03-15 | 2017-03-16 | N |
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2017-03-15 | 2017-03-16 | N |