Deficiency Records for Woodward Hills Health and Rehabilitation Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for Woodward Hills Health and Rehabilitation Ctr. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-05 | 2023-10-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-05 | 2023-10-25 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-05 | 2023-10-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-05 | 2023-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-05 | 2023-10-25 | 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 | 2023-10-05 | 2023-10-25 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-10-05 | 2023-10-25 | 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 | 2023-10-05 | 2023-10-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-05 | 2023-10-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-05 | 2023-10-25 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-10 | 2023-10-25 | 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 | 2023-10-10 | 2023-10-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-10 | 2023-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-10 | 2023-10-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-10 | 2023-10-25 | N |
| Have an externally vented heating system. | Fire Safety | 2023-10-10 | 2023-10-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-10 | 2023-10-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-10 | 2023-10-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-10 | 2023-10-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-10 | 2023-10-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-21 | 2023-10-12 | 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 | 2023-09-21 | 2023-10-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-21 | 2023-10-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-21 | 2023-10-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-21 | 2023-10-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-10-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-21 | 2023-10-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-21 | 2023-10-12 | Y |
| 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 | 2023-09-21 | 2023-10-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-21 | 2023-10-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-21 | 2023-10-12 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-09-21 | 2023-10-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-09-28 | 2022-12-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-28 | 2022-12-15 | 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 | 2022-09-28 | 2022-12-15 | 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 | 2022-09-28 | 2022-12-15 | 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 | 2022-09-28 | 2022-12-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-28 | 2022-12-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-09-28 | 2022-12-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-09-28 | 2022-12-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-28 | 2022-12-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-28 | 2022-12-15 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-28 | 2022-12-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-28 | 2022-12-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-28 | 2022-12-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-28 | 2022-10-27 | 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 | 2022-09-28 | 2022-10-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-28 | 2022-10-25 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-09-28 | 2022-10-25 | 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 | 2022-09-28 | 2022-10-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-28 | 2022-10-25 | 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 | 2022-09-28 | 2022-10-25 | 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 | 2022-09-28 | 2022-10-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-28 | 2022-10-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-28 | 2022-10-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-28 | 2022-10-25 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-04 | 2022-10-21 | 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 | 2022-10-04 | 2022-10-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-04 | 2022-10-21 | 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 | 2022-10-04 | 2022-10-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-04 | 2022-10-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-12 | 2021-11-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-12 | 2021-11-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-12 | 2021-11-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-09-09 | 2021-10-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-09 | 2021-10-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-08-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-15 | 2021-06-28 | 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 | 2021-05-28 | 2021-06-28 | N |
| 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 | 2021-05-28 | 2021-06-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-28 | 2021-06-28 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-28 | 2021-06-28 | 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 | 2021-05-28 | 2021-06-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-28 | 2021-06-28 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-05-28 | 2021-06-28 | 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 | 2021-05-28 | 2021-06-28 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2021-05-28 | 2021-06-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-28 | 2021-06-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-28 | 2021-06-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-28 | 2021-06-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-28 | 2021-06-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-28 | 2021-06-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-28 | 2021-06-28 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-26 | 2021-06-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-26 | 2021-06-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-26 | 2021-06-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-26 | 2021-06-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-26 | 2021-06-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-26 | 2021-06-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-05-26 | 2021-06-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-15 | 2021-05-14 | Y |
