A list of the most recent deficiencies for Western Reserve Masonic Comm. 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 appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-24 | 2023-11-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-24 | 2022-10-12 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-08-23 | 2022-08-26 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-08-22 | 2019-09-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-22 | 2019-09-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-22 | 2019-09-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-08-19 | 2019-09-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-08-19 | 2019-09-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-08-19 | 2019-09-20 | N |
| Establish methods for sharing information. | Fire Safety | 2019-08-19 | 2019-09-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-08-19 | 2019-09-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-19 | 2019-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-19 | 2019-09-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-08-19 | 2019-09-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-19 | 2019-09-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-06-25 | 2018-09-07 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-06-25 | 2018-09-07 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-06-25 | 2018-09-07 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-06-25 | 2018-09-07 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-06-25 | 2018-09-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-06-25 | 2018-09-07 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2018-06-25 | 2018-09-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-06-25 | 2018-09-07 | N |
