Deficiency Records for Western Hills Healthcare Residence
Updated as of November 01, 2018
This is not the most recent data for Western Hills Healthcare Residence. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-09-14 | 2018-09-15 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-14 | 2018-09-15 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-09-14 | 2018-09-14 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-02-01 | 2018-03-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-02-01 | 2018-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-01 | 2018-03-15 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-02-01 | 2018-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-01 | 2018-03-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-02-01 | 2018-02-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-02-01 | 2018-02-28 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-01-29 | 2018-02-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-01-29 | 2018-01-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-01-29 | 2018-01-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-01-29 | 2018-01-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-01-29 | 2018-01-30 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2018-01-29 | 2018-01-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-08-17 | 2017-08-24 | Y |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-08-17 | 2017-08-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2017-05-19 | 2017-05-20 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-05-19 | 2017-05-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-12-20 | 2017-01-19 | N |
| Provide care for each resident in a way that maintains or improves their quality of life. | Health | 2016-12-20 | 2017-01-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-12-20 | 2017-01-19 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-12-20 | 2017-01-19 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-12-20 | 2017-01-19 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-12-20 | 2017-01-19 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2016-12-20 | 2017-01-19 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-12-20 | 2017-01-19 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-12-20 | 2017-01-19 | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-12-20 | 2017-01-19 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2016-12-14 | 2017-01-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2016-12-14 | 2017-01-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2016-12-14 | 2017-01-13 | N |
| Try to resolve each resident's complaints quickly. | Health | 2016-10-25 | 2016-11-21 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-10-25 | 2016-11-21 | Y |
| 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. | Health | 2016-10-25 | 2016-11-21 | Y |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-03-01 | 2016-04-14 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-03-01 | 2016-04-14 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-03-01 | 2016-04-14 | N |
| 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. | Health | 2016-02-18 | 2016-03-18 | Y |
