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Deficiency Records for Serenity Spring Senior Living at Northwood
A list of the most recent deficiencies for Serenity Spring Senior Living at Northwood. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Serenity Spring Senior Living at Northwood. 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? |
---|---|---|---|---|
Conduct testing and exercise requirements. | Fire Safety | 2024-06-04 | 2024-07-15 | 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 | 2024-06-04 | 2024-07-15 | 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 | 2024-06-04 | 2024-07-15 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-06-04 | 2024-07-15 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-04 | 2024-07-15 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-04 | 2024-07-15 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-04 | 2024-07-15 | N |
Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2024-06-04 | 2024-07-15 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-22 | 2024-07-01 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-22 | 2024-07-01 | 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 | 2024-05-22 | 2024-07-01 | N |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-05-22 | 2024-07-01 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-22 | 2024-07-01 | N |
Respond appropriately to all alleged violations. | Health | 2024-05-22 | 2024-07-01 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-22 | 2024-07-01 | 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 | 2024-05-22 | 2024-07-01 | N |
Ensure each resident receives an accurate assessment. | Health | 2024-05-22 | 2024-07-01 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-22 | 2024-07-01 | 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 | 2024-05-22 | 2024-07-01 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-22 | 2024-07-01 | 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 | 2024-05-22 | 2024-07-01 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-22 | 2024-07-01 | N |
Post nurse staffing information every day. | Health | 2024-05-22 | 2024-07-01 | 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 | 2024-05-22 | 2024-07-01 | 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 | 2024-05-22 | 2024-07-01 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-22 | 2024-07-01 | N |
Provide and implement an infection prevention and control program. | Health | 2024-05-22 | 2024-07-01 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-22 | 2024-07-01 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-05-22 | 2024-07-01 | N |
Address patient/client population and determine types of services needed. | Fire Safety | 2024-06-04 | 2024-06-28 | N |
Establish staff and initial training requirements. | Fire Safety | 2024-06-04 | 2024-06-28 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-04 | 2024-06-28 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2024-06-04 | 2024-06-28 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-04 | 2024-06-28 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-04 | 2024-06-28 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-12 | 2023-12-26 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-09 | 2023-04-13 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-09 | 2023-04-13 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-09 | 2023-03-24 | 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 | 2023-02-09 | 2023-03-24 | N |
Post nurse staffing information every day. | Health | 2023-02-09 | 2023-03-24 | 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 | 2023-02-09 | 2023-03-24 | N |
Ensure staff are vaccinated for COVID-19 | Health | 2023-02-09 | 2023-03-24 | N |
Provide and implement an infection prevention and control program. | Health | 2023-02-09 | 2023-03-24 | Y |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Establish policies and procedures for medical documentation. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Create arrangements with other facilities to receive patients. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Develop a communication plan. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Establish emergency prep training and testing. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Establish staff and initial training requirements. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Conduct testing and exercise requirements. | Fire Safety | 2023-02-20 | 2023-03-08 | 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 | 2023-02-20 | 2023-03-08 | N |
Provide properly protected cooking facilities. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-20 | 2023-03-08 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-31 | 2022-09-23 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-31 | 2022-09-23 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-21 | 2022-01-24 | Y |
Implement emergency and standby power systems. | Fire Safety | 2019-07-22 | 2019-08-21 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-22 | 2019-08-21 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-22 | 2019-08-21 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-22 | 2019-08-21 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-22 | 2019-08-21 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-22 | 2019-08-21 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-06 | 2019-06-26 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-06 | 2019-06-26 | 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 | 2019-06-06 | 2019-06-26 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-06 | 2019-06-26 | N |
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