Deficiency Records for Western Hills Healthcare Residence
Updated as of November 01, 2020
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? |
|---|---|---|---|---|
| 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 |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-09-13 | 2019-09-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-08-23 | 2019-09-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-08-23 | 2019-09-30 | 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 | 2019-06-21 | 2019-07-25 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-21 | 2019-07-25 | Y |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-03-13 | 2019-04-08 | 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 | 2019-03-13 | 2019-04-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-13 | 2019-04-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-03-13 | 2019-04-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-03-13 | 2019-04-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-13 | 2019-04-08 | 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 | 2019-03-13 | 2019-04-08 | N |
| Post nurse staffing information every day. | Health | 2019-03-13 | 2019-04-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-13 | 2019-04-08 | N |
| Keep all essential equipment working safely. | Health | 2019-03-13 | 2019-04-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-02-05 | 2019-02-18 | Y |
| 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 | 2019-02-05 | 2019-02-18 | 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 | 2018-12-12 | 2018-12-26 | Y |
| Provide activities to meet all resident's needs. | Health | 2018-12-12 | 2018-12-26 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-12-12 | 2018-12-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-11-20 | 2018-11-21 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-09-25 | 2018-10-16 | Y |
| 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 |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-22 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-13 | Not Fixed | N |
