A list of the most recent deficiencies for Woodland Manor. 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? |
---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-21 | 2024-01-12 | Y |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-12-21 | 2024-01-12 | Y |
Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-08-09 | 2023-09-15 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-09 | 2023-09-15 | Y |
Implement emergency and standby power systems. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Add 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. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Conform to length requirements for dead end corridors. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Have exits that are accessible at all times. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Meet other general requirements that are deficient. | Fire Safety | 2023-04-05 | 2023-05-30 | 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 | 2023-04-05 | 2023-05-30 | N |
Provide properly protected cooking facilities. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Meet other general requirements that are deficient. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-04-05 | 2023-05-30 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-21 | 2023-05-08 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-21 | 2023-05-08 | Y |
Honor the resident's right to manage his or her financial affairs. | Health | 2023-03-21 | 2023-05-08 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-21 | 2023-05-08 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-21 | 2023-05-08 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-21 | 2023-05-08 | N |
Provide activities to meet all resident's needs. | Health | 2023-03-21 | 2023-05-08 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-21 | 2023-05-08 | 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 | 2023-03-21 | 2023-05-08 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-21 | 2023-05-08 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-21 | 2023-05-08 | 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 | 2023-03-21 | 2023-05-08 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-21 | 2023-05-08 | 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 | 2023-03-21 | 2023-05-08 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-21 | 2023-05-08 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-21 | 2023-05-08 | Y |
Ensure each resident receives an accurate assessment. | Health | 2022-06-15 | 2022-07-15 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-15 | 2022-07-15 | 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 | 2022-06-15 | 2022-07-15 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-15 | 2022-07-15 | Y |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-06-15 | 2022-07-15 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-25 | 2022-04-22 | Y |
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 | 2022-01-27 | 2022-02-25 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-27 | 2022-02-25 | N |
Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-02-25 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-17 | 2021-11-07 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-27 | 2021-10-25 | N |
Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2021-07-27 | 2021-10-25 | 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 | 2021-09-03 | 2021-10-25 | Y |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-17 | 2021-09-30 | 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 | 2021-08-17 | 2021-09-30 | N |
Provide properly protected cooking facilities. | Fire Safety | 2021-08-17 | 2021-09-30 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-17 | 2021-09-30 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-17 | 2021-09-30 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-17 | 2021-09-30 | N |
Provide properly sized and located linen or trash receptacles. | Fire Safety | 2021-08-17 | 2021-09-30 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-17 | 2021-09-30 | 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 | 2021-07-27 | 2021-08-27 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-27 | 2021-08-27 | N |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-07-27 | 2021-08-27 | N |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-07-27 | 2021-08-27 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-27 | 2021-08-27 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-07-27 | 2021-08-27 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-27 | 2021-08-27 | 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 | 2021-07-27 | 2021-08-27 | N |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-27 | 2021-08-27 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-27 | 2021-08-27 | 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 | 2021-07-27 | 2021-08-27 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-27 | 2021-08-27 | N |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-07-27 | 2021-08-27 | N |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-07-27 | 2021-08-27 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-27 | 2021-08-27 | 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 | 2021-07-27 | 2021-08-27 | 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 | 2021-07-27 | 2021-08-27 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-27 | 2021-08-27 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-27 | 2021-08-27 | N |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-07-27 | 2021-08-27 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-27 | 2021-08-27 | N |
Provide and implement an infection prevention and control program. | Health | 2021-07-27 | 2021-08-27 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-27 | 2021-08-27 | Y |
Conduct testing and exercise requirements. | Fire Safety | 2019-07-29 | 2019-08-28 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-29 | 2019-08-28 | N |
Provide properly protected cooking facilities. | Fire Safety | 2019-07-29 | 2019-08-28 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-29 | 2019-08-28 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-29 | 2019-08-28 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-29 | 2019-08-28 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-29 | 2019-08-28 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-29 | 2019-08-28 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-06-17 | 2019-07-17 | N |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-06-17 | 2019-07-17 | 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 | 2019-06-17 | 2019-07-17 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-17 | 2019-07-17 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-17 | 2019-07-17 | N |
Provide appropriate foot care. | Health | 2019-06-17 | 2019-07-17 | N |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-06-17 | 2019-07-17 | 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 | 2019-06-17 | 2019-07-17 | N |
Provide or obtain dental services for each resident. | Health | 2019-06-17 | 2019-07-17 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-17 | 2019-07-17 | N |
Provide and implement an infection prevention and control program. | Health | 2019-06-17 | 2019-07-17 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-17 | 2019-07-17 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-06-17 | 2019-07-17 | N |