Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

WESTY COMMUNITY CARE HOME

WESTMORELAND, KS · 40 certified beds · Last Life Safety survey September 18, 2024

CMS Certification Number 175471 · first certified December 2003

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

23
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
10
Inspection & testing records
Of the citations on file

Position within KS

23 citations — more than 34% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 1 citation; the earlier surveys in the window averaged 11. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (May 2026 to July 2026), and past the point by which nine in ten KS facilities have been surveyed. This facility’s last Life Safety survey was September 2024. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

4 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.

This facility23KS median27National median11
Citations on file over three years, compared
MeasureCitations
This facility23
Median facility in KS27
Median facility nationally11

Survey history

Citations at each Life Safety survey
162021-0962023-0312024-09
Citations at each Life Safety survey
Survey dateCitations
September 8, 202116
March 28, 20236
September 18, 20241

Most-cited tags

Most-cited tags at this facility
K-07123E-00061E-00391K-07111K-03541K-02111K-02221K-09011
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0712Have simulated fire drills held at unexpected times.32024-09-18
E-0006Conduct risk assessment and an All-Hazards approach.12021-09-08
E-0039Conduct testing and exercise requirements.12021-09-08
K-0711Provide a written emergency evacuation plan.12021-09-08
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.12023-03-28
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.12021-09-08
K-0222Add 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.12021-09-08
K-0901Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.12023-03-28

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 6
  • Emergency Preparedness Deficiencies 4
  • Miscellaneous Deficiencies 4
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Other 6
Citations by CMS category
CategoryCitations
Smoke Deficiencies6
Emergency Preparedness Deficiencies4
Miscellaneous Deficiencies4
Gas, Vacuum, and Electrical Systems Deficiencies3
Egress Deficiencies2
Construction Deficiencies2
Electrical Deficiencies1
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 18, 2024 — 1 citation

Citations issued on September 18, 2024
TagWhat the surveyor checksStatus
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (October 18, 2024)

March 28, 2023 — 6 citations

Citations issued on March 28, 2023
TagWhat the surveyor checksStatus
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (May 4, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (May 4, 2023)
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.Deficient, Provider has date of correction (May 4, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (May 4, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 4, 2023)
K-0901Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.Deficient, Provider has date of correction (May 4, 2023)

September 8, 2021 — 16 citations

Citations issued on September 8, 2021
TagWhat the surveyor checksStatus
E-0006Conduct risk assessment and an All-Hazards approach.Deficient, Provider has date of correction (October 20, 2021)
E-0007Address patient/client population and determine types of services needed.Deficient, Provider has date of correction (October 20, 2021)
E-0020Establish policies and procedures including evacuation.Deficient, Provider has date of correction (October 20, 2021)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (October 20, 2021)
K-0131Meet requirements for sections of health care facilities separated by fire resistive construction.Deficient, Provider has date of correction (October 20, 2021)
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (October 20, 2021)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (October 20, 2021)
K-0222Add 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.Deficient, Provider has date of correction (October 20, 2021)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (October 20, 2021)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 20, 2021)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (October 20, 2021)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (October 20, 2021)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (October 20, 2021)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (October 20, 2021)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (October 20, 2021)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (October 20, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.