Deficiency Records for Westgate Hills Rehab and Healthcare Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for Westgate Hills Rehab and Healthcare Ctr. 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-28 | 2022-02-11 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-12-28 | 2022-02-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-08-28 | 2020-09-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-08-28 | 2020-09-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-08-28 | 2020-09-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-08-28 | 2020-09-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-28 | 2020-03-31 | 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 | 2020-02-28 | 2020-03-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-28 | 2020-03-31 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-02-28 | 2020-03-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-28 | 2020-03-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-28 | 2020-03-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-28 | 2020-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-28 | 2020-03-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-28 | 2020-03-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-28 | 2020-03-31 | 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 | 2020-02-28 | 2020-03-31 | N |
| Post nurse staffing information every day. | Health | 2020-02-28 | 2020-03-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-02-28 | 2020-03-31 | 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 | 2020-02-28 | 2020-03-31 | N |
| 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 | 2020-02-28 | 2020-03-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-28 | 2020-03-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-02-28 | 2020-03-31 | N |
| Meet other general requirements. | Fire Safety | 2018-10-29 | 2018-12-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-29 | 2018-12-03 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-10-29 | 2018-12-03 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-10-29 | 2018-12-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-29 | 2018-12-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-29 | 2018-12-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-29 | 2018-12-03 | 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 | 2018-08-09 | 2018-09-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-09 | 2018-09-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-09 | 2018-09-18 | 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 | 2018-08-09 | 2018-09-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-09 | 2018-09-18 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-08-09 | 2018-09-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-09 | 2018-09-18 | N |
| Provide appropriate foot care. | Health | 2018-08-09 | 2018-09-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-09 | 2018-09-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-09 | 2018-09-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2018-08-09 | 2018-09-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-08-09 | 2018-09-18 | 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 | 2018-08-09 | 2018-09-18 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-08-09 | 2018-09-18 | N |
| Provide or obtain dental services for each resident. | Health | 2018-08-09 | 2018-09-18 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2018-08-09 | 2018-09-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-09 | 2018-09-18 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-05-26 | 2017-07-25 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-05-26 | 2017-07-25 | N |
| 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 | 2017-05-26 | 2017-07-25 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-05-26 | 2017-07-25 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-05-26 | 2017-07-25 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-05-26 | 2017-07-25 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-26 | 2017-07-25 | 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 | 2017-05-26 | 2017-07-25 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2017-05-26 | 2017-07-25 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-05-26 | 2017-07-25 | 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 | 2017-05-26 | 2017-07-25 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-05-26 | 2017-07-25 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-05-26 | 2017-07-25 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2017-05-26 | 2017-07-25 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-05-26 | 2017-07-25 | N |
| Provide or obtain laboratory services only when ordered by the attending physician. | Health | 2017-05-26 | 2017-07-25 | N |
| Quickly tell the resident's doctor the results of laboratory tests. | Health | 2017-05-26 | 2017-07-25 | N |
| Give or get x-rays and other tests in a timely manner to meet the needs of residents. | Health | 2017-05-26 | 2017-07-25 | N |
| Tell the attending physician the results of x-rays and other tests, in a timely manner. | Health | 2017-05-26 | 2017-07-25 | N |
| Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. | Health | 2017-05-26 | 2017-07-25 | N |
