A list of the most recent deficiencies for Western Convalescent Hospital. 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? |
|---|---|---|---|---|
| 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 | 2023-04-28 | 2023-05-18 | Y |
| 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 | 2023-04-28 | 2023-05-18 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-04-28 | 2023-05-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-28 | 2023-05-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-07 | 2023-04-13 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-01-18 | 2023-02-02 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-01-18 | 2023-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-14 | 2023-01-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-30 | 2022-04-12 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-12 | 2021-09-13 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-08-12 | 2021-09-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-12 | 2021-09-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-12 | 2021-09-13 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-08-12 | 2021-09-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-17 | 2021-09-03 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-17 | 2021-09-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-17 | 2021-09-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-17 | 2021-09-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-17 | 2021-09-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-17 | 2021-09-03 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2021-08-17 | 2021-09-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-17 | 2021-09-03 | 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 | 2021-08-17 | 2021-09-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-17 | 2021-09-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-17 | 2021-09-03 | N |
| Provide activities to meet all resident's needs. | Health | 2021-08-17 | 2021-09-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-17 | 2021-09-03 | 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 | 2021-08-17 | 2021-09-03 | 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 | 2021-08-17 | 2021-09-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-17 | 2021-09-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-17 | 2021-09-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-17 | 2021-09-03 | 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 | 2021-08-17 | 2021-09-03 | 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 | 2021-08-17 | 2021-09-03 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-08-17 | 2021-09-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-17 | 2021-09-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-08-17 | 2021-09-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-17 | 2021-09-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-24 | 2019-07-03 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-05-24 | 2019-07-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-05-24 | 2019-07-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-24 | 2019-07-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-24 | 2019-07-03 | 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 | 2019-05-24 | 2019-07-03 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-05-24 | 2019-07-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-24 | 2019-07-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-24 | 2019-07-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-05-25 | 2019-06-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-18 | 2018-06-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-05-18 | 2018-06-20 | 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 | 2018-05-18 | 2018-06-20 | N |
| Provide activities to meet all resident's needs. | Health | 2018-05-18 | 2018-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-18 | 2018-06-20 | 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 | 2018-05-18 | 2018-06-20 | 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 | 2018-05-18 | 2018-06-20 | 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 | 2018-05-18 | 2018-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-18 | 2018-06-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-05-18 | 2018-06-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-24 | 2018-06-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-12 | Not Fixed | N |
