A list of the most recent deficiencies for Als Woodstock Inc. 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 | 2024-01-25 | 2024-02-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-25 | 2024-02-12 | 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 | 2024-01-25 | 2024-02-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-25 | 2024-02-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-25 | 2024-02-12 | Y |
| 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 | 2024-01-25 | 2024-02-12 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-01-25 | 2024-02-12 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-12-27 | 2024-01-19 | Y |
| 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 | 2023-12-27 | 2024-01-19 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-10-10 | 2023-10-20 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-10-10 | 2023-10-20 | Y |
| 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 | 2023-10-10 | 2023-10-20 | Y |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2023-10-10 | 2023-10-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-10 | 2023-10-20 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-18 | 2023-10-20 | Y |
| 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 | 2021-10-14 | 2021-11-18 | 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 | 2021-10-12 | 2021-11-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-12 | 2021-11-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-04-25 | 2019-06-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-25 | 2019-06-06 | 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 | 2019-04-25 | 2019-06-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-25 | 2019-06-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-25 | 2019-06-06 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-25 | 2019-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-25 | 2019-06-06 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-04-25 | 2019-06-06 | 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 | 2019-04-25 | 2019-06-06 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-04-25 | 2019-06-06 | 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 | 2019-04-29 | 2019-06-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-29 | 2019-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-29 | 2019-06-06 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2018-02-22 | 2018-03-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-22 | 2018-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-22 | 2018-03-20 | 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 | 2018-02-21 | 2018-03-20 | N |
