Deficiency Records for The Greens at Westlake
Updated as of January 01, 2022
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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-15 | 2021-10-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-30 | 2021-10-29 | 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 | 2021-09-30 | 2021-10-29 | 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 | 2021-09-30 | 2021-10-29 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-09-30 | 2021-10-29 | 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 | 2021-05-28 | 2021-08-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-05-28 | 2021-07-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-28 | 2021-07-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-28 | 2021-07-28 | N |
| Post nurse staffing information every day. | Health | 2021-05-28 | 2021-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-28 | 2021-07-28 | N |
| Dispose of garbage and refuse properly. | Health | 2021-05-28 | 2021-07-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-05-28 | 2021-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-28 | 2021-07-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-28 | 2021-07-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-28 | 2021-07-28 | 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 | 2021-05-28 | 2021-07-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-28 | 2021-07-28 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-28 | 2021-07-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-28 | 2021-07-28 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-25 | 2021-07-26 | 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 | 2021-05-25 | 2021-07-26 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2021-05-25 | 2021-07-26 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-25 | 2021-07-26 | Y |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-05-25 | 2021-07-26 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-25 | 2021-07-26 | Y |
| Have a properly installed and maintained dumbwaiter or escalator. | Fire Safety | 2021-05-25 | 2021-07-26 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-05-25 | 2021-07-26 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-25 | 2021-07-26 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-25 | 2021-07-26 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-04-22 | 2021-05-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-22 | 2021-05-28 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-03-26 | 2021-05-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-26 | 2021-05-28 | Y |
| Provide appropriate foot care. | Health | 2021-03-26 | 2021-05-28 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-03-26 | 2021-05-28 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-03-26 | 2021-05-28 | Y |
| Post nurse staffing information every day. | Health | 2021-04-22 | 2021-05-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-12-31 | 2021-01-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-31 | 2021-01-29 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-12-08 | 2021-01-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-12-08 | 2021-01-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-12-08 | 2021-01-05 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2020-10-19 | 2020-11-04 | Y |
| 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 |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-28 | 2020-03-01 | 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 |
| 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 |
| Establish policies and procedures for volunteers. | 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 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 |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 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 |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-02-05 | 2019-03-18 | Y |
| Establish methods for sharing information. | Fire Safety | 2019-02-05 | 2019-03-18 | Y |
| 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 |
| 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 |
| 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 |
