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Deficiency Records for Western Convalescent Hospital

View the most recent health deficiencies and inspection results for Western Convalescent Hospital. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Western Convalescent Hospital. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Ensure services provided by the nursing facility meet professional standards of quality. Health 2026-04-29 2026-05-14 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2025-12-10 2025-12-31 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2025-09-18 2025-10-03 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2025-09-18 2025-10-03 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2025-09-18 2025-10-03 Y
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 2025-09-18 2025-10-03 Y
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2025-09-18 2025-10-03 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2025-08-27 2025-09-11 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-08-27 2025-09-11 Y
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Health 2025-08-27 2025-09-11 Y
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 2025-08-27 2025-09-11 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-04-08 2025-04-21 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-04-08 2025-04-21 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2025-03-21 2025-04-11 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2025-03-21 2025-04-11 N
Ensure that residents are free from significant medication errors. Health 2025-03-21 2025-04-11 N
Ensure medication error rates are not 5 percent or greater. Health 2025-03-21 2025-04-11 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 2025-03-21 2025-04-11 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2025-03-21 2025-04-11 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 2025-03-21 2025-04-11 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 2025-03-21 2025-04-11 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-03-21 2025-04-11 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 2025-03-21 2025-04-11 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2025-03-21 2025-04-11 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 2025-03-21 2025-04-11 N
Ensure each resident receives an accurate assessment. Health 2025-03-21 2025-04-11 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2025-03-21 2025-04-11 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 2025-03-21 2025-04-11 N
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2025-03-21 2025-04-11 N
Provide and implement an infection prevention and control program. Health 2025-03-21 2025-04-11 N
Have a policy regarding use and storage of foods brought to residents by family and other visitors. Health 2025-03-21 2025-04-11 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2025-03-21 2025-04-11 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 2025-01-29 2025-02-18 Y
Provide and implement an infection prevention and control program. Health 2025-01-29 2025-02-18 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 2024-12-11 2024-12-26 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-10-29 2024-11-14 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-10-29 2024-11-14 Y
Provide and implement an infection prevention and control program. Health 2024-10-29 2024-11-14 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-10-25 2024-11-08 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 2024-10-25 2024-11-08 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-08-22 2024-09-03 Y
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 2024-03-22 2024-04-12 N
Keep residents' personal and medical records private and confidential. Health 2024-03-22 2024-04-12 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-03-22 2024-04-12 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-03-22 2024-04-12 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-22 2024-04-12 N
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 2024-03-22 2024-04-12 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 2024-03-22 2024-04-12 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-03-22 2024-04-12 N
Provide and implement an infection prevention and control program. Health 2024-03-22 2024-04-12 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2024-03-22 2024-04-12 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2024-03-22 2024-04-12 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-08-23 2023-09-07 Y
Install an approved automatic sprinkler system. Fire Safety 2021-08-17 2021-09-13 N
Have power receptacles that are properly grounded. Fire Safety 2021-08-17 2021-09-13 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-08-17 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 2021-08-17 2021-09-13 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2021-08-17 2021-09-13 N
Provide and implement an infection prevention and control program. 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
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
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
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 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 medication error rates are not 5 percent or greater. 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
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 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 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 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 activities to meet all resident's needs. 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
Ensure services provided by the nursing facility meet professional standards of quality. 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
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
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
PASARR screening for Mental disorders or Intellectual Disabilities Health 2021-08-17 2021-09-03 N
Ensure each resident receives an accurate assessment. 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
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
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
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
Ensure proper usage of power strips and extension cords. Fire Safety 2021-08-17 2021-08-17 N

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