A list of the most recent deficiencies for Westhaven Nursing Home. 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? |
|---|---|---|---|---|
| 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 | 2023-11-29 | 2024-01-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-26 | 2023-09-13 | 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 | 2023-07-26 | 2023-09-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-17 | 2023-07-24 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-17 | 2023-07-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-01-26 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2020-03-09 | 2020-04-27 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-03-09 | 2020-04-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-03-09 | 2020-04-27 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2020-03-09 | 2020-04-27 | 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 | 2020-03-09 | 2020-04-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-03-03 | 2020-03-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-03 | 2020-03-20 | 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 | 2020-03-03 | 2020-03-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-01-23 | 2019-04-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-01-23 | 2019-04-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-23 | 2019-04-01 | 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 | 2019-01-23 | 2019-04-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-01-23 | 2019-04-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-23 | 2019-04-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-01-23 | 2019-04-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-23 | 2019-04-01 | 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 | 2019-01-23 | 2019-04-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-23 | 2019-04-01 | 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 | 2019-01-23 | 2019-04-01 | N |
| Provide or obtain dental services for each resident. | Health | 2019-01-23 | 2019-04-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-23 | 2019-04-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-23 | 2019-04-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-01-15 | 2019-03-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-15 | 2019-03-11 | N |
