A list of the most recent deficiencies for Woodhaven 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? |
|---|---|---|---|---|
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-01 | 2024-03-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-01 | 2024-03-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-01 | 2024-03-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-01 | 2024-03-11 | 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 | 2024-02-01 | 2024-03-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-01 | 2024-03-11 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-02-01 | 2024-03-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-02-01 | 2024-03-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-01 | 2024-03-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-01 | 2024-03-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-28 | 2022-10-26 | 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 | 2022-07-28 | 2022-10-06 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-07-28 | 2022-09-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-28 | 2022-09-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-28 | 2022-09-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-28 | 2022-09-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-28 | 2022-09-12 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-28 | 2022-09-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-28 | 2022-08-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-06 | 2020-01-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-06 | 2020-01-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-11-06 | 2020-01-03 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2019-11-06 | 2020-01-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-06 | 2020-01-03 | 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 | 2019-11-06 | 2020-01-03 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-11-06 | 2020-01-03 | 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 | 2019-11-06 | 2020-01-03 | 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 | 2019-11-06 | 2020-01-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-06 | 2020-01-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-06 | 2020-01-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-06 | 2020-01-03 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-11-06 | 2020-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-06 | 2020-01-03 | N |
