Deficiency Records for Westridge Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Westridge Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-07 | 2023-10-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-15 | 2023-01-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-15 | 2023-01-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-15 | 2023-01-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-07 | 2022-12-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-21 | 2022-10-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-05 | 2022-10-06 | Y |
| 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 | 2022-07-20 | 2022-09-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-20 | 2022-09-28 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2022-08-25 | 2022-09-13 | 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 | 2022-07-20 | 2022-08-20 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-07-20 | 2022-08-20 | N |
| Provide appropriate foot care. | Health | 2022-07-20 | 2022-08-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-20 | 2022-08-20 | N |
| Provide activities to meet all resident's needs. | Health | 2022-07-20 | 2022-08-20 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-20 | 2022-08-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-26 | 2022-05-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-20 | 2022-05-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-02 | 2022-03-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-15 | 2022-01-15 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-09-20 | 2021-10-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-20 | 2021-10-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-19 | 2021-09-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-19 | 2021-09-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-09-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-19 | 2021-09-13 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-19 | 2021-09-13 | Y |
| 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 | 2021-08-19 | 2021-09-13 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-08-19 | 2021-09-13 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-16 | 2021-05-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-16 | 2021-05-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-16 | 2021-05-16 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-04-16 | 2021-05-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-16 | 2021-05-16 | Y |
| Dispose of garbage and refuse properly. | Health | 2021-04-16 | 2021-05-16 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-04-15 | 2021-05-15 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-04-15 | 2021-05-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-15 | 2021-05-15 | 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 | 2021-04-15 | 2021-05-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-04-15 | 2021-05-15 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-04-15 | 2021-05-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-15 | 2021-05-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-04-15 | 2021-05-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-15 | 2021-05-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-15 | 2021-05-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-15 | 2021-05-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-16 | 2021-04-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-16 | 2021-04-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-16 | 2021-04-17 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-23 | 2019-07-22 | 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 | 2019-05-23 | 2019-07-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-05-23 | 2019-07-22 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-05-23 | 2019-07-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-23 | 2019-06-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-23 | 2019-06-21 | 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 | 2019-05-23 | 2019-06-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-23 | 2019-06-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-05-23 | 2019-06-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-23 | 2019-06-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-18 | Not Fixed | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-18 | Not Fixed | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-23 | Not Fixed | N |
