Deficiency Records for The Greens at Westlake
Updated as of November 01, 2020
This is not the most recent data for The Greens at Westlake. For the most recent information, click here.
A list of the most recent deficiencies for The Greens at 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 the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2020-02-28 | 2020-03-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-25 | 2019-05-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-25 | 2019-05-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-04-25 | 2019-05-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-25 | 2019-05-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-15 | 2019-05-21 | 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 | 2019-04-15 | 2019-05-21 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Establish methods for sharing information. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-05 | 2019-03-18 | 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 | 2019-02-05 | 2019-03-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Be properly staffed | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-05 | 2019-03-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-02-05 | 2019-03-18 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-05 | 2019-03-18 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-02-05 | 2019-03-18 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-02-07 | 2019-03-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-07 | 2019-03-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-07 | 2019-03-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-07 | 2019-03-18 | 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 | 2019-02-07 | 2019-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-07 | 2019-03-18 | N |
| Dispose of garbage and refuse properly. | Health | 2019-02-07 | 2019-03-18 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-02-07 | 2019-03-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-02-07 | 2019-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-27 | 2018-10-12 | Y |
| 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 | 2018-07-23 | 2018-07-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-04-25 | 2018-04-26 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-04-10 | 2018-04-26 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2017-12-28 | 2018-02-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-12-28 | 2018-02-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-12-28 | 2018-02-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-12-28 | 2018-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-28 | 2018-02-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-12-28 | 2018-02-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-12-28 | 2018-02-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-12-28 | 2018-02-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2017-12-29 | 2018-02-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-29 | 2018-02-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2017-12-29 | 2018-02-15 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-07-21 | 2017-08-18 | Y |
| 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 | 2017-07-21 | 2017-08-18 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-07-21 | 2017-08-18 | Y |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-07-21 | 2017-08-18 | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-07-21 | 2017-08-18 | Y |
| Offer other nutritional food to each resident who will not eat the food served. | Health | 2017-07-21 | 2017-08-18 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-07-21 | 2017-08-18 | Y |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-10-03 | 2016-10-28 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-10-03 | 2016-10-28 | N |
| Try to resolve each resident's complaints quickly. | Health | 2016-10-06 | 2016-10-28 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-10-06 | 2016-10-28 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-10-06 | 2016-10-28 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2016-10-06 | 2016-10-28 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-10-06 | 2016-10-28 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-10-06 | 2016-10-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-10-06 | 2016-10-28 | N |
