A list of the most recent deficiencies for Western Hills Healthcare Residence. 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 implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-08 | 2023-03-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-08 | 2023-03-09 | Y |
| 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 | 2023-02-08 | 2023-03-09 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-02-08 | 2023-03-09 | 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 | 2023-02-08 | 2023-03-09 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-02-08 | 2023-03-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-08 | 2023-03-09 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-09 | 2023-03-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-10 | 2022-05-31 | Y |
| 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 | 2021-11-11 | 2021-12-24 | Y |
| Ensure resident rooms meet each resident's needs. | Health | 2021-11-11 | 2021-12-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-11 | 2021-12-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-11 | 2021-12-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-11 | 2021-12-11 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-11-11 | 2021-12-11 | 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 | 2021-11-11 | 2021-12-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-11 | 2021-12-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-11 | 2021-12-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-22 | 2020-03-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-22 | 2020-03-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-01-22 | 2020-03-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-22 | 2020-03-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-22 | 2020-02-21 | 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 | 2020-01-22 | 2020-02-21 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2020-01-22 | 2020-02-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-22 | 2020-02-11 | 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 | 2020-01-22 | 2020-02-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-22 | 2020-02-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-22 | 2020-02-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-22 | 2020-01-27 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-01-22 | 2020-01-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-22 | 2020-01-23 | N |
