A list of the most recent deficiencies for Wilshire at Lakewood Rehab Center. 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 manage his or her financial affairs. | Health | 2023-11-21 | 2024-01-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-21 | 2024-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-21 | 2024-01-05 | 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 | 2023-11-21 | 2024-01-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-21 | 2024-01-05 | N |
| Provide appropriate foot care. | Health | 2023-11-21 | 2024-01-05 | N |
| 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 | 2023-11-21 | 2024-01-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-21 | 2024-01-05 | 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 | 2023-11-21 | 2024-01-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-21 | 2024-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-21 | 2024-01-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-21 | 2024-01-05 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-11-21 | 2024-01-05 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-11-21 | 2024-01-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-21 | 2024-01-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-21 | 2024-01-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-21 | 2024-01-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-21 | 2024-01-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-21 | 2024-01-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-21 | 2024-01-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-21 | 2024-01-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-21 | 2024-01-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-24 | 2023-02-24 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-11-07 | 2022-12-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-07 | 2022-12-20 | 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 | 2022-11-07 | 2022-12-20 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-11-07 | 2022-12-20 | Y |
| 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 | 2022-11-07 | 2022-12-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-07 | 2022-12-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-07 | 2022-12-20 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-11-07 | 2022-12-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-11 | 2022-08-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-24 | 2022-06-24 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-03-22 | 2022-04-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-22 | 2022-04-29 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-22 | 2022-04-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-22 | 2022-04-29 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-03-22 | 2022-04-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-22 | 2022-04-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-22 | 2022-04-29 | N |
| 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 | 2022-03-22 | 2022-04-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-22 | 2022-04-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-22 | 2022-04-29 | 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 | 2022-03-22 | 2022-04-29 | 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 | 2022-03-22 | 2022-04-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-22 | 2022-04-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-22 | 2022-04-29 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-03-22 | 2022-04-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-22 | 2022-04-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-22 | 2022-04-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-22 | 2022-04-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-22 | 2022-04-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-22 | 2022-04-29 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-04-12 | 2022-04-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-22 | 2022-03-22 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-29 | 2022-02-12 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-12-29 | 2022-02-12 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-31 | 2021-02-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-31 | 2020-03-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-01-31 | 2020-03-16 | 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 | 2020-01-31 | 2020-03-16 | 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 | 2020-01-31 | 2020-03-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-31 | 2020-03-16 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-01-31 | 2020-03-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-31 | 2020-03-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-31 | 2020-03-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-31 | 2020-03-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-31 | 2020-03-16 | N |
| 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 | 2020-01-31 | 2020-03-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-31 | 2020-03-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-01-31 | 2020-03-16 | 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 | 2020-01-31 | 2020-03-16 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2020-01-31 | 2020-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-31 | 2020-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-31 | 2020-03-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-17 | Not Fixed | Y |
