A list of the most recent deficiencies for Stonebridge Westphalia. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-23 | 2023-03-01 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-02 | 2023-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-02 | 2023-01-10 | N |
| Post nurse staffing information every day. | Health | 2022-12-02 | 2023-01-06 | 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 | 2022-12-02 | 2023-01-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-02 | 2023-01-06 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-02 | 2023-01-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-02 | 2023-01-06 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-12-02 | 2023-01-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-12-02 | 2023-01-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-02 | 2023-01-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-02 | 2023-01-06 | 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 | 2022-12-02 | 2023-01-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-12-02 | 2022-12-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-02 | 2022-12-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-02 | 2022-12-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-06 | 2022-10-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-06 | 2022-10-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-17 | 2022-09-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-04-18 | 2019-05-24 | 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 | 2018-05-11 | 2018-07-19 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-05-11 | 2018-07-19 | N |
| 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 | 2018-05-11 | 2018-07-19 | 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 | 2018-05-11 | 2018-07-19 | 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 | 2018-05-11 | 2018-07-19 | 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 | 2018-05-11 | 2018-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-11 | 2018-06-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-05-11 | 2018-06-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-11 | 2018-06-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-11 | 2018-06-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-05-11 | 2018-06-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-11 | 2018-06-19 | N |
