A list of the most recent deficiencies for Rae-Ann Westlake. 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-08 | 2024-02-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-08 | 2024-02-15 | 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 | 2024-02-08 | 2024-02-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-08 | 2024-02-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-08 | 2024-02-15 | N |
| Have policies on smoking. | Health | 2024-02-08 | 2024-02-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-06 | 2024-02-15 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2024-02-06 | 2024-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-06 | 2024-02-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-06 | 2024-02-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-06 | 2024-02-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-06 | 2024-02-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-02-06 | 2024-02-15 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2024-02-06 | 2024-02-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-06 | 2024-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-13 | 2023-11-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-26 | 2023-07-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-26 | 2023-07-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-01 | 2023-06-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-01 | 2023-06-02 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-10 | 2023-04-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-22 | 2023-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-09-16 | 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 | 2022-09-15 | 2022-09-16 | 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 | 2022-09-15 | 2022-09-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-15 | 2022-09-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-30 | 2021-11-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-30 | 2021-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-30 | 2021-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-30 | 2021-11-19 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-27 | 2021-11-19 | 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 | 2021-09-27 | 2021-11-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-09-27 | 2021-11-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-27 | 2021-11-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-27 | 2021-11-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-27 | 2021-11-19 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-09-27 | 2021-11-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-16 | 2019-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-16 | 2019-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-16 | 2019-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-16 | 2019-06-14 | N |
