A list of the most recent deficiencies for Embassy of Woodview. 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-09 | 2024-02-23 | 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 | 2024-02-09 | 2024-02-23 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-09-27 | 2023-10-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-27 | 2023-10-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-27 | 2023-10-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-27 | 2023-10-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-06 | 2023-03-17 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-11-22 | 2023-02-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-22 | 2023-02-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-22 | 2023-02-03 | 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 | 2022-11-22 | 2023-02-03 | 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 | 2022-11-22 | 2023-02-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-22 | 2023-02-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-22 | 2023-02-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-11-22 | 2023-02-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-22 | 2023-02-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-22 | 2023-02-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-11-22 | 2023-02-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-22 | 2023-02-03 | 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 | 2022-11-22 | 2023-02-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-22 | 2023-02-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-11-22 | 2023-02-03 | 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 | 2022-11-22 | 2023-02-03 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-11-22 | 2023-02-03 | N |
| Provide or obtain dental services for each resident. | Health | 2022-11-22 | 2023-02-03 | 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 | 2022-11-22 | 2023-02-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-22 | 2023-02-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-30 | 2023-02-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-30 | 2023-02-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-30 | 2023-02-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-30 | 2023-02-03 | 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 | 2022-11-14 | 2023-02-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-14 | 2023-02-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-14 | 2023-02-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-14 | 2023-02-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-14 | 2023-02-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-14 | 2023-02-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-14 | 2023-02-03 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2022-11-22 | 2023-01-02 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-22 | 2023-01-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-23 | 2022-09-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-08 | 2022-09-19 | 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 | 2022-07-07 | 2022-09-19 | Y |
| Post nurse staffing information every day. | Health | 2022-07-07 | 2022-09-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-01 | 2022-09-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-01 | 2022-09-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-01 | 2022-09-19 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-01 | 2022-09-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-01 | 2022-09-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-20 | 2022-09-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-13 | 2021-09-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-13 | 2021-09-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-26 | 2021-05-05 | 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 | 2021-04-26 | 2021-05-05 | Y |
| 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 | 2021-04-26 | 2021-05-05 | 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 | 2020-03-12 | 2020-05-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-12 | 2020-05-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-12 | 2020-05-26 | 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 | 2020-03-12 | 2020-05-26 | N |
| Provide or obtain dental services for each resident. | Health | 2020-03-12 | 2020-05-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-10 | 2020-05-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-24 | 2019-02-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-01-24 | 2019-02-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-01-24 | 2019-02-15 | N |
| Respond appropriately to all alleged violations. | Health | 2019-01-24 | 2019-02-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-24 | 2019-02-15 | 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 | 2019-01-24 | 2019-02-15 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-01-24 | 2019-02-15 | N |
| Provide or obtain dental services for each resident. | Health | 2019-01-24 | 2019-02-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-01-24 | 2019-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-23 | 2019-02-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-23 | 2019-02-15 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-01-23 | 2019-02-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-23 | 2019-02-15 | N |
