A list of the most recent deficiencies for Hunter Woods Nursing and Rehab. 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-02-12 | 2024-03-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-12 | 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 | 2024-02-12 | 2024-03-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-02-12 | 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 | 2024-02-12 | 2024-03-11 | 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 | 2024-02-12 | 2024-03-11 | 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 | 2024-02-12 | 2024-03-11 | 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 | 2024-02-12 | 2024-03-11 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-02-12 | 2024-03-11 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2024-02-12 | 2024-03-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-12 | 2024-03-11 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-12 | 2024-03-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-12 | 2024-03-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-12 | 2024-03-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-12 | 2024-03-11 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-13 | 2023-12-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-13 | 2023-12-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-13 | 2023-09-29 | Y |
| 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 | 2023-12-13 | 2023-09-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-13 | 2023-09-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-11 | 2023-09-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-25 | 2023-09-11 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-05-25 | 2023-09-11 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-25 | 2023-09-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-25 | 2023-09-11 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-25 | 2023-09-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-25 | 2023-09-11 | Y |
| 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 | 2022-08-25 | 2022-10-09 | 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 | 2022-08-25 | 2022-10-09 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-08-25 | 2022-10-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-25 | 2022-10-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-25 | 2022-10-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-15 | 2022-08-24 | 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 | 2022-07-15 | 2022-08-24 | 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 | 2022-07-15 | 2022-08-24 | 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 | 2022-07-15 | 2022-08-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-15 | 2022-08-24 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-07-15 | 2022-08-24 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-19 | 2022-02-16 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-19 | 2022-02-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-19 | 2022-02-16 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-01-19 | 2022-02-16 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-30 | 2021-10-25 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-08-31 | 2021-10-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-31 | 2021-10-06 | N |
| Post nurse staffing information every day. | Health | 2021-08-31 | 2021-10-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-31 | 2021-10-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-31 | 2021-10-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-31 | 2021-10-06 | Y |
| Have a combustible roofing system that meets safety standards. | Fire Safety | 2019-09-26 | 2019-12-18 | 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 | 2019-09-26 | 2019-12-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-26 | 2019-12-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-26 | 2019-12-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-26 | 2019-12-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-26 | 2019-12-18 | N |
