Deficiency Records for Westmoreland Rehabilitation and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Westmoreland Rehabilitation and Healthcare Center. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-08 | 2023-07-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-08 | 2023-07-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-08 | 2023-07-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-07-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-08 | 2023-07-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-08 | 2023-07-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-08 | 2023-07-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-08 | 2023-07-15 | 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 | 2023-06-08 | 2023-07-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-08 | 2023-07-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-08 | 2023-07-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-06-08 | 2023-07-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-08 | 2023-07-15 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-08 | 2023-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-12 | 2023-07-06 | 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 | 2022-02-21 | 2022-04-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-21 | 2022-04-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-21 | 2022-04-26 | N |
| Have enough space near smoke barriers to protect residents. | Fire Safety | 2022-02-21 | 2022-04-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-21 | 2022-04-26 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-02-21 | 2022-04-26 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2022-02-21 | 2022-04-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-17 | 2022-03-18 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-02-17 | 2022-03-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-02-17 | 2022-03-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-17 | 2022-03-18 | 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 | 2022-02-17 | 2022-03-18 | 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 | 2022-02-17 | 2022-03-18 | N |
| Post nurse staffing information every day. | Health | 2022-02-17 | 2022-03-18 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-02-17 | 2022-03-18 | 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 | 2022-02-17 | 2022-03-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-02-17 | 2022-03-18 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-02-17 | 2022-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-17 | 2022-03-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-17 | 2022-03-18 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-17 | 2022-03-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-17 | 2022-03-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-17 | 2022-03-18 | Y |
| 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 | 2022-02-17 | 2022-03-18 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-17 | 2022-03-18 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-02-17 | 2022-03-18 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-02-17 | 2022-03-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-02-17 | 2022-03-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-03-11 | 2019-05-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-11 | 2019-05-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-11 | 2019-05-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-11 | 2019-05-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-07 | 2019-03-22 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-02-07 | 2019-03-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-02-07 | 2019-03-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-02-07 | 2019-03-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-07 | 2019-03-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-07 | 2019-03-22 | N |
| Respond appropriately to all alleged violations. | Health | 2019-02-07 | 2019-03-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-07 | 2019-03-22 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-02-07 | 2019-03-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-07 | 2019-03-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-07 | 2019-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-07 | 2019-03-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-07 | 2019-03-22 | 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 | 2019-02-07 | 2019-03-22 | 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 | 2019-02-07 | 2019-03-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-02-07 | 2019-03-22 | 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 | 2019-02-07 | 2019-03-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-07 | 2019-03-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-07 | 2019-03-22 | N |
