A list of the most recent deficiencies for Wayne Woodlands Manor. 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 receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-08-30 | 2023-09-20 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-31 | 2023-07-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-31 | 2023-07-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-31 | 2023-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-31 | 2023-07-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-19 | 2023-07-11 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-05-19 | 2023-07-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-19 | 2023-07-11 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-05-19 | 2023-07-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-05-19 | 2023-07-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-19 | 2023-07-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-19 | 2023-07-11 | 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 | 2023-05-19 | 2023-07-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-19 | 2023-07-11 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-19 | 2023-07-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-19 | 2023-07-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-19 | 2023-07-11 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-05-19 | 2023-07-11 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-19 | 2023-07-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-19 | 2023-07-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-19 | 2023-07-11 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-05-19 | 2023-07-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-19 | 2023-07-11 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-19 | 2023-07-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-01 | 2022-08-30 | 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 | 2022-07-01 | 2022-08-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-07-01 | 2022-08-30 | 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 | 2022-07-01 | 2022-08-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-01 | 2022-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-01 | 2022-08-30 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-07-01 | 2022-08-30 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-07-01 | 2022-08-30 | 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 | 2022-07-01 | 2022-08-30 | 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 | 2022-07-01 | 2022-08-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-01 | 2022-08-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-07-01 | 2022-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-01 | 2022-08-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-07-01 | 2022-08-30 | N |
| Report COVID19 data to residents and families. | Health | 2022-07-01 | 2022-08-30 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-07-01 | 2022-08-30 | N |
| Use approved construction type or materials. | Fire Safety | 2022-07-12 | 2022-08-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-07-12 | 2022-08-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-07-12 | 2022-08-05 | 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 | 2021-09-14 | 2021-10-12 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-14 | 2021-10-12 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-13 | 2021-10-12 | 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 | 2021-08-13 | 2021-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-13 | 2021-10-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-13 | 2021-10-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-13 | 2021-10-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-13 | 2021-10-12 | 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 | 2021-08-13 | 2021-10-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-08-13 | 2021-10-12 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-13 | 2021-10-12 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-14 | 2021-10-12 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-24 | 2021-10-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-24 | 2021-10-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-24 | 2021-10-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-08-24 | 2021-10-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-24 | 2021-10-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-16 | Not Fixed | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-11-16 | Not Fixed | Y |
