A list of the most recent deficiencies for Westover Retirement Community. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-05 | 2021-12-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-05 | 2021-12-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-05 | 2021-12-06 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-10-05 | 2021-12-06 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-11-06 | 2021-12-06 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-29 | 2021-12-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-09-29 | 2021-12-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-29 | 2021-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-29 | 2021-12-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-29 | 2021-12-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-20 | 2020-04-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-18 | 2020-04-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-18 | 2020-04-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-18 | 2020-04-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-18 | 2020-04-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-12-28 | 2019-02-05 | 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 | 2018-12-28 | 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 | 2018-12-28 | 2019-02-05 | 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 | 2018-12-28 | 2019-02-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-28 | 2019-02-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-12-28 | 2019-02-05 | 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 | 2018-12-28 | 2019-02-05 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2018-12-28 | 2019-02-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-12-28 | 2019-02-05 | N |
