Deficiency Records for Western Hills Retirement Village

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Updated as of March 01, 2024

A list of the most recent deficiencies for Western Hills Retirement Village. 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 that residents are free from significant medication errors. Health 2023-07-11 2023-07-19 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-03-04 2022-03-14 Y
Meet requirements for sections of health care facilities separated by fire resistive construction. Fire Safety 2021-09-21 2022-02-14 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-09-23 2021-12-03 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 2021-09-23 2021-12-03 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-09-23 2021-12-03 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 2021-09-23 2021-12-03 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2021-09-23 2021-12-03 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 2021-09-23 2021-12-03 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 2021-09-23 2021-12-03 N
Provide and implement an infection prevention and control program. Health 2021-09-23 2021-12-03 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-09-23 2021-12-03 Y
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-09-21 2021-12-03 N
Install an approved automatic sprinkler system. Fire Safety 2021-09-21 2021-12-03 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-09-21 2021-12-03 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-09-21 2021-12-03 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-07-26 2021-08-06 Y
Provide and implement an infection prevention and control program. Health 2021-03-09 2021-03-24 N
Use approved construction type or materials. Fire Safety 2020-02-26 2020-07-31 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 2020-02-26 2020-07-31 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 2020-02-26 2020-07-31 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2020-02-26 2020-07-31 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2020-02-26 2020-03-27 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2020-02-26 2020-03-27 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2020-02-26 2020-03-27 N
Provide a written emergency evacuation plan. Fire Safety 2020-02-26 2020-03-27 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2020-02-26 2020-03-27 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2020-02-26 2020-03-27 N
Have proper medical gas storage and administration areas. Fire Safety 2020-02-26 2020-03-27 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 2018-12-13 2019-02-05 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2018-12-13 2019-02-05 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2018-12-13 2019-02-05 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2018-12-13 2019-02-05 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2018-12-13 2019-02-05 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2018-12-13 2019-02-05 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 2018-12-13 2019-02-05 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2018-12-10 2019-02-05 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2018-12-10 2019-02-05 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2018-12-10 2019-02-05 N
Provide a written emergency evacuation plan. Fire Safety 2018-12-10 2019-02-05 N
Have simulated fire drills held at unexpected times. Fire Safety 2018-12-10 2019-02-05 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2018-12-10 2019-02-05 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2018-12-10 2019-02-05 N
Ensure proper usage of power strips and extension cords. Fire Safety 2018-12-10 2019-02-05 N