Deficiency Records for Western Hills Retirement Village
Updated as of May 01, 2020
This is not the most recent data for Western Hills Retirement Village. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Be properly staffed | 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 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-05 | 2020-02-27 | 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 ne | Health | 2020-02-05 | 2020-02-27 | Y |
| 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 |
| Be properly staffed | 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 |
| 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 |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-10-04 | 2017-11-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-10-04 | 2017-11-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-10-04 | 2017-11-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-10-04 | 2017-11-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-10-04 | 2017-11-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-10-04 | 2017-11-24 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-10-05 | 2017-11-24 | N |
