Westy Community Care Home

FEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0801 · Deficient, Provider has date of correction (Sep 27, 2024)

FElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Potential for more than minimal harm · Administration Deficiencies · Tag F0851 · Deficient, Provider has date of correction (Sep 27, 2024)

FDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0882 · Deficient, Provider has date of correction (Sep 27, 2024)

EDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (Sep 27, 2024)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (Sep 27, 2024)

DEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (Sep 27, 2024)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Deficient, Provider has date of correction (Sep 27, 2024)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Sep 27, 2024)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Mar 12, 2024)

DHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Oct 25, 2023)

FHave 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.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0727 · Deficient, Provider has date of correction (Apr 19, 2023)

DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Deficient, Provider has date of correction (May 19, 2023)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Deficient, Provider has date of correction (May 19, 2023)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (Apr 19, 2023)

DPlan the resident's discharge to meet the resident's goals and needs.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0660 · Deficient, Provider has date of correction (Apr 19, 2023)

DEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0661 · Deficient, Provider has date of correction (May 19, 2023)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Deficient, Provider has date of correction (Apr 19, 2023)

DProvide medically-related social services to help each resident achieve the highest possible quality of life.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0745 · Deficient, Provider has date of correction (Apr 19, 2023)

DImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (May 19, 2023)