Deficiency Records for Mentor Woods Skilled Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Mentor Woods Skilled Nursing and Rehabilitation. 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? |
|---|---|---|---|---|
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-03 | 2024-02-09 | Y |
| 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 | 2022-04-01 | 2022-04-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-04-01 | 2022-04-28 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-04-01 | 2022-04-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-01 | 2022-04-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-01 | 2022-04-28 | 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 | 2022-04-01 | 2022-04-28 | 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 | 2022-04-01 | 2022-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-01 | 2022-04-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-03-28 | 2022-04-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-28 | 2022-04-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-28 | 2022-04-28 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2022-03-28 | 2022-04-28 | 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 | 2022-02-18 | 2022-03-14 | 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 | 2022-02-18 | 2022-03-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-18 | 2022-03-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-07 | 2022-03-14 | 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 | 2022-02-07 | 2022-03-14 | 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 | 2022-02-07 | 2022-03-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-19 | 2021-12-11 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-11-19 | 2021-12-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-07 | 2021-06-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-01 | 2021-06-11 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-03-07 | 2019-04-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-07 | 2019-04-22 | 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 | 2019-03-06 | 2019-04-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-03-06 | 2019-04-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-06 | 2019-04-22 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-03-06 | 2019-04-22 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-02-14 | 2018-03-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-02-14 | 2018-03-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-02-14 | 2018-03-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-02-14 | 2018-03-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-02-13 | 2018-03-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-02-13 | 2018-03-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-02-13 | 2018-03-30 | 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 | 2018-02-13 | 2018-03-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-02-13 | 2018-03-30 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-02-13 | 2018-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-02-13 | 2018-03-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-02-13 | 2018-03-30 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-02-13 | 2018-03-30 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-02-13 | 2018-03-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-02-13 | 2018-03-30 | N |
