A list of the most recent deficiencies for Towne Manor West. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-24 | 2023-10-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-24 | 2023-10-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-24 | 2023-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-24 | 2023-10-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-24 | 2023-10-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-24 | 2023-10-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-24 | 2023-10-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-24 | 2023-10-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-08-24 | 2023-10-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-24 | 2023-10-03 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-08-03 | 2023-09-11 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-03 | 2023-09-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-03 | 2023-09-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-03 | 2023-09-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-03 | 2023-09-11 | 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 | 2023-08-03 | 2023-09-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-03 | 2023-09-11 | N |
| Dispose of garbage and refuse properly. | Health | 2023-08-03 | 2023-09-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-16 | 2023-06-20 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-05-16 | 2023-06-20 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-16 | 2023-06-20 | Y |
| Meet other general requirements. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-27 | 2022-08-29 | 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 | 2022-07-27 | 2022-08-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-27 | 2022-08-29 | N |
| Respond appropriately to all alleged violations. | Health | 2022-06-21 | 2022-07-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-21 | 2022-07-25 | 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 | 2022-06-21 | 2022-07-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-21 | 2022-07-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-21 | 2022-07-25 | 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 | 2022-06-21 | 2022-07-25 | 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 | 2022-06-21 | 2022-07-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-21 | 2022-07-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-21 | 2022-07-25 | Y |
| Meet other general requirements. | Fire Safety | 2021-04-12 | 2021-06-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-12 | 2021-06-29 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-04-12 | 2021-05-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-12 | 2021-05-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-04-12 | 2021-05-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-12 | 2021-05-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-12 | 2021-05-24 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2021-04-12 | 2021-05-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-12 | 2021-05-24 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-04-09 | 2021-05-17 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-04-09 | 2021-05-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-09 | 2021-05-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-09 | 2021-05-17 | 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 | 2021-04-09 | 2021-05-17 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-04-09 | 2021-05-17 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-09 | 2021-05-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-09 | 2021-05-17 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-04-09 | 2021-05-17 | 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 | 2021-04-09 | 2021-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-09 | 2021-05-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-09 | 2021-05-17 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2021-04-09 | 2021-05-17 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2021-04-09 | 2021-05-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-09 | 2021-05-17 | 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 | 2021-04-09 | 2021-05-17 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-04-09 | 2021-05-17 | N |
| Report COVID19 data to residents and families. | Health | 2021-04-09 | 2021-05-17 | 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 | 2021-04-09 | 2021-05-17 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-09 | 2021-05-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-09 | 2021-05-17 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-04-09 | 2021-05-17 | Y |
