Deficiency Records for Woodcrest Post Acute and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Woodcrest Post Acute 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-28 | 2023-11-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-27 | 2023-11-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-19 | 2023-09-29 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-14 | 2023-09-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-17 | 2023-06-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-03 | 2023-04-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-10 | 2023-02-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-12 | 2023-01-29 | Y |
| Provide or obtain dental services for each resident. | Health | 2022-10-27 | 2022-11-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-27 | 2022-11-02 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-09-27 | 2022-10-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-27 | 2022-10-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-06 | 2022-07-18 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-23 | 2022-04-04 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2021-09-28 | 2021-11-02 | N |
| Use approved construction type or materials. | Fire Safety | 2021-09-28 | 2021-11-02 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-09-28 | 2021-11-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-28 | 2021-11-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-28 | 2021-11-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-28 | 2021-11-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-28 | 2021-11-02 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-09-28 | 2021-11-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-28 | 2021-11-02 | 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 | 2021-09-24 | 2021-10-29 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-09-24 | 2021-10-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-24 | 2021-10-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-24 | 2021-10-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-24 | 2021-10-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-24 | 2021-10-29 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-24 | 2021-10-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-24 | 2021-10-29 | 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 | 2021-09-24 | 2021-10-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-24 | 2021-10-29 | 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 | 2021-09-24 | 2021-10-29 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-09-24 | 2021-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-24 | 2021-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-24 | 2021-10-29 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-09-24 | 2021-10-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-10 | 2021-06-17 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-04-19 | 2021-05-17 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-12 | 2020-06-12 | 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 | 2020-02-12 | 2020-06-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-12 | 2020-06-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-10 | 2020-03-12 | 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 | 2020-02-10 | 2020-03-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-02-10 | 2020-03-12 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-02-10 | 2020-03-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-10 | 2020-03-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-10 | 2020-03-12 | 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 | 2020-02-10 | 2020-03-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-10 | 2020-03-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-10 | 2020-03-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-02-10 | 2020-03-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-02-10 | 2020-03-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-02-10 | 2020-03-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-10 | 2020-03-12 | 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 | 2020-02-10 | 2020-03-12 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-02-10 | 2020-03-12 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2020-02-10 | 2020-03-12 | 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 | 2020-02-10 | 2020-03-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-10 | 2020-03-12 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2020-02-10 | 2020-03-12 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-02-10 | 2020-03-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-02-10 | 2020-03-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-10 | 2020-03-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-02-10 | 2020-03-12 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-04-16 | 2019-05-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-16 | 2019-05-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-04-16 | 2019-05-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-16 | 2019-05-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-16 | 2019-05-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-16 | 2019-05-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-14 | 2019-04-11 | 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 | 2019-02-14 | 2019-04-11 | 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 | 2019-02-14 | 2019-04-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-14 | 2019-04-11 | 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 | 2019-02-14 | 2019-03-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-02-14 | 2019-03-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-14 | 2019-03-27 | 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 | 2019-02-14 | 2019-03-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-14 | 2019-03-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-14 | 2019-03-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-02-14 | 2019-03-27 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-02-14 | 2019-03-27 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-02-14 | 2019-03-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-14 | 2019-03-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-02-14 | 2019-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-14 | 2019-03-27 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-02-14 | 2019-03-27 | N |
