Deficiency Records for Westchester Manor at Providence Place
Updated as of July 01, 2021
This is not the most recent data for Westchester Manor at Providence Place. For the most recent information, click here.
A list of the most recent deficiencies for Westchester Manor at Providence Place. 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 and implement an infection prevention and control program. | Health | 2020-12-31 | 2021-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-05-15 | 2020-06-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-08 | 2019-10-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-08 | 2019-10-22 | 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 | 2019-08-29 | 2019-09-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-29 | 2019-09-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-29 | 2019-09-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-29 | 2019-09-26 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-09 | 2018-11-12 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-10-09 | 2018-11-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-09 | 2018-11-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-09-19 | 2018-10-17 | 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 | 2018-09-19 | 2018-10-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-19 | 2018-10-17 | 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 | 2018-09-19 | 2018-10-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-09-19 | 2018-10-17 | 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 | 2018-09-19 | 2018-10-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-19 | 2018-10-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-19 | 2018-10-17 | 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 | 2018-09-19 | 2018-10-17 | 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 | 2018-09-19 | 2018-10-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-09-19 | 2018-10-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-09-19 | 2017-11-22 | 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 | 2017-08-10 | 2017-11-10 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-08-10 | 2017-11-10 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-10 | 2017-11-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-08-10 | 2017-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-09-19 | 2017-11-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-09-19 | 2017-11-03 | N |
| Provide housekeeping and maintenance services. | Health | 2017-08-10 | 2017-10-12 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-10 | 2017-10-12 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-08-10 | 2017-10-12 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-10 | 2017-10-12 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2017-08-10 | 2017-10-12 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-08-10 | 2017-09-07 | N |
