Deficiency Records for Extended Care Hospital of Westminster
Updated as of March 01, 2024
A list of the most recent deficiencies for Extended Care Hospital of Westminster. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-28 | 2023-10-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-02 | 2023-03-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-20 | 2023-02-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-03 | 2022-11-04 | 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 | 2022-09-07 | 2022-10-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-07 | 2022-10-07 | 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 | 2022-09-07 | 2022-10-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-07 | 2022-10-07 | 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 | 2022-09-07 | 2022-10-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-07 | 2022-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-07 | 2022-10-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-07 | 2022-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-07 | 2022-10-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-07 | 2022-10-07 | N |
| Dispose of garbage and refuse properly. | Health | 2022-09-07 | 2022-10-07 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-06 | 2022-09-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-06 | 2022-09-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-06 | 2022-09-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-06 | 2022-09-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-07 | 2021-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-07 | 2021-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-28 | 2021-10-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-28 | 2021-10-18 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-16 | 2019-08-16 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-07-16 | 2019-08-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-16 | 2019-08-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-16 | 2019-08-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-16 | 2019-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-16 | 2019-08-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-16 | 2019-08-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-16 | 2019-08-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-02 | 2019-07-31 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-07-02 | 2019-07-31 | 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 | 2019-07-02 | 2019-07-31 | N |
| Provide activities to meet all resident's needs. | Health | 2019-07-02 | 2019-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-02 | 2019-07-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-02 | 2019-07-31 | 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 | 2019-07-02 | 2019-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-02 | 2019-07-31 | N |
| Keep all essential equipment working safely. | Health | 2019-07-02 | 2019-07-31 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-02 | 2019-07-31 | N |
| Develop a communication plan. | Fire Safety | 2018-09-25 | 2018-10-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-09-25 | 2018-10-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-09-25 | 2018-10-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-25 | 2018-10-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-09-25 | 2018-10-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-25 | 2018-10-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-09-25 | 2018-10-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-25 | 2018-10-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-25 | 2018-10-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-06-19 | 2018-07-18 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-06-19 | 2018-07-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-19 | 2018-07-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-19 | 2018-07-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-06-19 | 2018-07-18 | 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 | 2018-06-19 | 2018-07-18 | 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 | 2018-06-19 | 2018-07-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-19 | 2018-07-18 | N |
| Dispose of garbage and refuse properly. | Health | 2018-06-19 | 2018-07-18 | N |
