A list of the most recent deficiencies for West Side House Ltc Facility. 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? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-19 | 2023-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-07 | 2023-10-04 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-09-07 | 2023-09-29 | N |
| Provide activities to meet all resident's needs. | Health | 2023-09-07 | 2023-09-29 | 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 | 2023-09-07 | 2023-09-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-07 | 2023-09-29 | 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 | 2023-09-07 | 2023-09-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-07 | 2023-09-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-07 | 2023-09-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-10 | 2022-03-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-10 | 2022-03-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-10 | 2022-03-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-02-10 | 2022-03-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-10 | 2022-03-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-02 | 2022-03-23 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-02-02 | 2022-03-23 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-02-02 | 2022-03-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-02 | 2022-03-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-02-02 | 2022-03-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-02 | 2022-03-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-02 | 2022-03-23 | 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 | 2022-02-02 | 2022-03-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-02 | 2022-03-23 | 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 | 2022-02-02 | 2022-03-23 | N |
| Post nurse staffing information every day. | Health | 2022-02-02 | 2022-03-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-02 | 2022-03-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-02 | 2022-03-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-03-23 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-02-02 | 2022-03-23 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-02 | 2022-03-23 | 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 | 2021-03-24 | 2021-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-24 | 2021-06-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-24 | 2021-06-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-24 | 2021-06-15 | N |
| Provide activities to meet all resident's needs. | Health | 2021-03-24 | 2021-05-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-03-24 | 2021-05-06 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-03-24 | 2021-05-06 | N |
