A list of the most recent deficiencies for Woodland Post-Acute. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Develop a communication plan. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Establish methods for sharing information. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Use approved construction type or materials. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-18 | 2024-01-31 | 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 | 2023-12-18 | 2024-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-18 | 2024-01-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-14 | 2023-12-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-14 | 2023-12-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-14 | 2023-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-14 | 2023-12-28 | 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 | 2023-12-14 | 2023-12-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-14 | 2023-12-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-14 | 2023-12-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-14 | 2023-12-28 | 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 | 2023-12-14 | 2023-12-28 | 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 | 2023-12-14 | 2023-12-28 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-14 | 2023-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-14 | 2023-12-28 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-12-14 | 2023-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2023-12-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-12-14 | 2023-12-28 | N |
| Have policies on smoking. | Health | 2023-12-14 | 2023-12-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-03 | 2023-11-01 | Y |
| 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 | 2023-10-03 | 2023-11-01 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-06-14 | 2023-07-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-14 | 2023-07-18 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-01 | 2023-06-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-07 | 2023-04-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-07 | 2023-04-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-07 | 2023-04-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-15 | 2023-04-21 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-11-16 | 2022-12-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-16 | 2022-12-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-11 | 2022-11-14 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-04-07 | 2022-05-02 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-04-07 | 2022-05-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-07 | 2022-05-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-07 | 2022-05-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-07 | 2022-05-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-07 | 2022-05-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-07 | 2022-05-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-04-07 | 2022-05-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-18 | 2022-03-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-18 | 2022-03-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-02-18 | 2022-03-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-18 | 2022-03-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-02-18 | 2022-03-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-18 | 2022-03-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-18 | 2022-03-31 | 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 | 2022-02-18 | 2022-03-31 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-02-18 | 2022-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-18 | 2022-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-18 | 2022-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-08-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-03 | 2021-06-08 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-08-14 | 2019-09-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-14 | 2019-09-03 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-14 | 2019-09-03 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-08-14 | 2019-09-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-14 | 2019-09-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-14 | 2019-09-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-14 | 2019-09-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-14 | 2019-09-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-14 | 2019-09-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-14 | 2019-09-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-19 | 2019-07-09 | 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 | 2019-06-19 | 2019-07-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-19 | 2019-07-09 | N |
