Deficiency Records for Woodlands Skilled Nursing and Therapy
Updated as of March 01, 2024
A list of the most recent deficiencies for Woodlands Skilled Nursing and Therapy. 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-09 | 2023-02-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-09 | 2023-02-27 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-01-09 | 2023-02-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-09 | 2023-02-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-01-09 | 2023-02-27 | 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 | 2023-01-09 | 2023-02-27 | 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 | 2023-01-09 | 2023-02-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-09 | 2023-02-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-09 | 2023-02-27 | Y |
| 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 | 2023-01-09 | 2023-02-27 | Y |
| 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 | 2023-01-09 | 2023-02-27 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-01-09 | 2023-02-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-09 | 2023-02-27 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-09 | 2023-02-27 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-07 | 2023-02-27 | 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 | 2023-02-07 | 2023-02-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-07 | 2023-02-27 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-04-26 | 2021-05-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-26 | 2021-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-26 | 2021-05-31 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-21 | 2021-05-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-21 | 2021-05-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-02-04 | 2019-03-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-04 | 2019-03-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-04 | 2019-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-29 | 2019-03-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-29 | 2019-03-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-01-29 | 2019-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-29 | 2019-03-04 | N |
