A list of the most recent deficiencies for Althea Woodland Nursing Home. 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-09 | 2021-06-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-09 | 2021-06-07 | Y |
| 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 | 2021-04-09 | 2021-06-07 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2021-04-07 | 2021-06-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-04-07 | 2021-06-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-04-07 | 2021-06-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-07 | 2021-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-07 | 2021-06-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-04-07 | 2021-06-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-22 | 2019-09-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-22 | 2019-09-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-11 | 2019-09-10 | 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 | 2019-07-11 | 2019-09-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-07-11 | 2019-09-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-07-11 | 2019-09-10 | 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 | 2019-07-11 | 2019-09-10 | 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 | 2019-07-11 | 2019-09-10 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2019-07-11 | 2019-09-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-11 | 2019-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-11 | 2019-09-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-07-11 | 2019-09-10 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-07-22 | 2019-08-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-22 | 2019-08-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-22 | 2019-07-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-22 | 2019-07-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-06-21 | 2018-10-30 | 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 | 2018-06-21 | 2018-09-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-06-21 | 2018-09-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-06-21 | 2018-09-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-06-21 | 2018-09-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-06-21 | 2018-09-12 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-06-22 | 2018-08-21 | 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 | 2018-06-22 | 2018-08-21 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2018-06-22 | 2018-08-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-22 | 2018-08-21 | 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 | 2018-06-22 | 2018-08-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-06-22 | 2018-08-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-06-22 | 2018-08-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-06-22 | 2018-08-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-22 | 2018-08-21 | N |
| Provide activities to meet all resident's needs. | Health | 2018-06-22 | 2018-08-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-22 | 2018-08-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-22 | 2018-08-21 | 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 | 2018-06-22 | 2018-08-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-22 | 2018-08-21 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-06-22 | 2018-08-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-22 | 2018-08-21 | N |
