Deficiency Records for Woodland Hills Healthcare and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Woodland Hills Healthcare 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-22 | 2023-12-20 | 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 | 2023-11-22 | 2023-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-22 | 2023-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-22 | 2023-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-22 | 2023-12-20 | 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 | 2023-11-22 | 2023-12-20 | 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 | 2023-11-22 | 2023-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-22 | 2023-12-20 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-11-22 | 2023-12-20 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-11-22 | 2023-12-20 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-11-22 | 2023-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-22 | 2023-12-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-11-21 | 2023-12-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-21 | 2023-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-01 | 2023-06-23 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-09 | 2023-01-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-09 | 2023-01-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-09 | 2023-01-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-09 | 2023-01-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-09 | 2023-01-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-09 | 2023-01-08 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-12-01 | 2022-12-31 | 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 | 2022-12-01 | 2022-12-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-01 | 2022-12-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-01 | 2022-12-31 | 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 | 2022-12-01 | 2022-12-31 | 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 | 2022-12-01 | 2022-12-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-01 | 2022-12-31 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-01 | 2022-12-31 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-12-01 | 2022-12-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-01 | 2022-12-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-25 | 2022-06-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-25 | 2022-06-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-25 | 2022-06-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-02 | 2022-04-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-02 | 2022-04-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-02 | 2022-04-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-02 | 2022-02-25 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-19 | 2021-11-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-30 | 2021-08-29 | 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 | 2021-07-30 | 2021-08-29 | 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 | 2021-07-30 | 2021-08-29 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-30 | 2021-08-29 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-07-30 | 2021-08-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-30 | 2021-08-29 | 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 | 2021-07-30 | 2021-08-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-30 | 2021-08-29 | 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 | 2021-07-30 | 2021-08-29 | 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 | 2021-07-30 | 2021-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-30 | 2021-08-29 | N |
| Dispose of garbage and refuse properly. | Health | 2021-07-30 | 2021-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-30 | 2021-08-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-30 | 2021-08-29 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-07-30 | 2021-08-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-30 | 2021-08-29 | 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 | 2021-07-30 | 2021-08-29 | Y |
| Install proper backup exit lighting. | Fire Safety | 2021-07-28 | 2021-08-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-28 | 2021-08-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-28 | 2021-08-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-18 | 2021-04-08 | Y |
