Deficiency Records for Westgate Hills Rehabilitation and Nursing Ctr
Updated as of August 01, 2021
This is not the most recent data for Westgate Hills Rehabilitation and Nursing Ctr. For the most recent information, click here.
A list of the most recent deficiencies for Westgate Hills Rehabilitation and Nursing Ctr. 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? |
|---|---|---|---|---|
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-11-19 | 2019-12-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-11-19 | 2019-12-24 | N |
| Establish methods for sharing information. | Fire Safety | 2019-11-19 | 2019-12-24 | N |
| Meet other general requirements. | Fire Safety | 2019-11-19 | 2019-12-24 | N |
| Use approved construction type or materials. | Fire Safety | 2019-11-19 | 2019-12-24 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-11-19 | 2019-12-24 | 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 | 2019-11-19 | 2019-12-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-19 | 2019-12-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-19 | 2019-12-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-19 | 2019-12-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-19 | 2019-12-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-11-19 | 2019-12-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-06 | 2019-12-17 | 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 | 2019-11-06 | 2019-12-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-06 | 2019-12-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-06 | 2019-12-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-06 | 2019-12-17 | 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 | 2019-11-06 | 2019-12-17 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2019-11-06 | 2019-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-06 | 2019-12-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-06 | 2019-12-17 | Y |
| 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 | 2019-03-30 | 2019-05-14 | Y |
| Meet other general requirements. | Fire Safety | 2018-10-16 | 2019-01-03 | 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 | 2018-10-16 | 2019-01-03 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-10-16 | 2019-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-16 | 2019-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-16 | 2019-01-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-16 | 2019-01-03 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-10-16 | 2018-12-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-16 | 2018-12-12 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2018-10-16 | 2018-12-12 | 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 | 2018-10-16 | 2018-12-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-10-16 | 2018-12-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-16 | 2018-12-12 | 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 | 2018-10-16 | 2018-12-12 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-10-16 | 2018-12-12 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Develop a communication plan. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Establish methods for sharing information. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-16 | 2018-12-08 | 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 | 2018-10-16 | 2018-12-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-10-16 | 2018-12-08 | N |
| Meet other general requirements. | Fire Safety | 2017-12-21 | 2018-02-13 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-12-21 | 2018-02-13 | 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 | 2017-12-21 | 2018-02-13 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2017-12-21 | 2018-02-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-12-21 | 2018-02-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-12-21 | 2018-02-13 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2017-12-14 | 2018-02-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-14 | 2018-02-06 | N |
| Respond appropriately to all alleged violations. | Health | 2017-12-14 | 2018-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2017-12-14 | 2018-02-06 | N |
