A list of the most recent deficiencies for Westmoreland 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? |
|---|---|---|---|---|
| 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 | 2023-12-19 | 2024-01-05 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-08-09 | 2023-08-28 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-08-09 | 2023-08-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-09 | 2023-08-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-09 | 2023-08-28 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-08-09 | 2023-08-28 | Y |
| Post nurse staffing information every day. | Health | 2023-01-18 | 2023-02-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-18 | 2023-02-06 | Y |
| 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 | 2022-08-02 | 2022-12-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-08-02 | 2022-12-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-02 | 2022-12-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-02 | 2022-12-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-02 | 2022-12-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-02 | 2022-12-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-02 | 2022-12-25 | 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 | 2022-08-02 | 2022-10-19 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-08-02 | 2022-10-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-02 | 2022-10-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-08-02 | 2022-10-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-02 | 2022-10-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-02 | 2022-10-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-02 | 2022-10-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-08-02 | 2022-10-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-02 | 2022-10-19 | N |
| Dispose of garbage and refuse properly. | Health | 2022-08-02 | 2022-10-19 | N |
| 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 | 2022-08-02 | 2022-10-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-02 | 2022-10-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-02 | 2022-10-19 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-02 | 2022-10-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-02 | 2022-10-19 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-08-02 | 2022-10-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-02 | 2022-10-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-02 | 2022-10-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-02 | 2022-10-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-02 | 2022-10-19 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-08-02 | 2022-08-22 | 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 | 2022-05-17 | 2022-06-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-17 | 2022-06-06 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-17 | 2022-06-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-04 | 2022-06-06 | 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 | 2022-04-04 | 2022-06-06 | 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 | 2022-04-04 | 2022-06-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-04 | 2022-06-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-04 | 2022-06-06 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-01-27 | 2022-02-17 | Y |
| 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 | 2021-12-14 | 2021-12-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-14 | 2021-12-31 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-20 | 2021-12-31 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-27 | 2021-10-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-27 | 2021-10-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-27 | 2021-10-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-15 | 2021-10-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-15 | 2021-10-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-15 | 2021-10-22 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-08-20 | 2021-10-22 | 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 | 2021-05-06 | 2021-05-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-09 | 2021-03-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-09 | 2021-03-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-08-22 | 2019-10-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-22 | 2019-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-22 | 2019-10-08 | 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 | 2019-08-22 | 2019-10-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-22 | 2019-10-08 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-08-22 | 2019-10-08 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-08-22 | 2019-10-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-22 | 2019-10-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-08-22 | 2019-10-08 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-08-22 | 2019-10-08 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-22 | 2019-10-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-22 | 2019-10-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-16 | 2018-08-23 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-07-16 | 2018-08-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-07-16 | 2018-08-23 | 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 | 2018-07-16 | 2018-08-23 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-16 | 2018-08-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-07-16 | 2018-08-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-16 | 2018-08-23 | N |
| Provide activities to meet all resident's needs. | Health | 2018-07-16 | 2018-08-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-16 | 2018-08-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-07-16 | 2018-08-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-16 | 2018-08-23 | 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 | 2018-07-16 | 2018-08-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-07-16 | 2018-08-23 | 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 | 2018-07-16 | 2018-08-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-07-16 | 2018-08-23 | 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 | 2018-07-16 | 2018-08-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-07-16 | 2018-08-23 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-07-11 | 2018-08-23 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2018-07-11 | 2018-08-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-07-11 | 2018-08-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-11 | 2018-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-11 | 2018-08-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-11 | 2018-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-07-11 | 2018-08-23 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-07-11 | 2018-08-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-07-11 | 2018-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-11 | 2018-08-23 | N |
