Deficiency Records for West Hickory Haven
Updated as of July 01, 2023
This is not the most recent data for West Hickory Haven. For the most recent information, click here.
A list of the most recent deficiencies for West Hickory Haven. 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 each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-03-09 | 2023-04-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-09 | 2023-04-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-04-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-09 | 2023-04-29 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-03-09 | 2023-04-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-03-09 | 2023-04-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-09 | 2023-04-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-09 | 2023-04-06 | 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 | 2023-03-09 | 2023-04-06 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-10 | 2023-03-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-03-10 | 2023-03-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-03-10 | 2023-03-31 | 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 | 2023-03-10 | 2023-03-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-10 | 2023-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-10 | 2023-03-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-10 | 2023-03-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-10 | 2023-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-10 | 2023-03-31 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-12-20 | 2023-01-25 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-12-20 | 2023-01-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-20 | 2023-01-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-20 | 2023-01-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-20 | 2023-01-25 | 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 | 2022-12-20 | 2023-01-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-20 | 2023-01-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-12-20 | 2023-01-25 | Y |
| 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 | 2021-11-18 | 2021-12-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-18 | 2021-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-18 | 2021-12-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-18 | 2021-12-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-18 | 2021-12-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-18 | 2021-12-17 | 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 | 2021-11-18 | 2021-12-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-18 | 2021-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-18 | 2021-12-17 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2021-11-18 | 2021-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2021-12-17 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-11-18 | 2021-12-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-18 | 2021-12-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-18 | 2021-12-17 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-01-28 | 2021-02-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-01-28 | 2021-02-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-29 | 2021-01-26 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2020-01-08 | 2020-02-04 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-01-08 | 2020-02-04 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2020-01-08 | 2020-02-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-08 | 2020-02-04 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-01-08 | 2020-02-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-07 | 2020-02-04 | N |
