Deficiency Records for Wayne Woodlands Manor
Updated as of October 01, 2020
This is not the most recent data for Wayne Woodlands Manor. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-11-26 | 2019-12-30 | Y |
| 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 | 2019-11-26 | 2019-12-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-26 | 2019-12-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-12 | 2019-06-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-11 | 2019-06-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-11 | 2019-06-25 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-04-11 | 2019-06-12 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-04-11 | 2019-06-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-11 | 2019-06-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-11 | 2019-06-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-11 | 2019-06-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-11 | 2019-06-12 | 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 | 2019-04-11 | 2019-06-12 | 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 | 2019-04-11 | 2019-06-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-11 | 2019-06-12 | 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 | 2019-04-11 | 2019-06-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-11 | 2019-06-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-04-11 | 2019-06-12 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-04-11 | 2019-06-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-11 | 2019-06-12 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-04-11 | 2019-06-12 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-04-11 | 2019-06-12 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-04-11 | 2019-06-12 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-16 | 2019-05-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-16 | 2019-05-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-16 | 2019-05-17 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-04-16 | 2019-05-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-16 | 2019-05-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-05-04 | 2018-07-12 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-05-07 | 2018-06-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-05-07 | 2018-06-21 | N |
| Use approved construction type or materials. | Fire Safety | 2018-05-07 | 2018-06-21 | 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 | 2018-05-07 | 2018-06-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-07 | 2018-06-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-04 | 2018-06-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-05-04 | 2018-06-18 | 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 | 2018-05-04 | 2018-06-18 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-05-04 | 2018-06-18 | 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 | 2018-05-04 | 2018-06-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-04 | 2018-06-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-05-04 | 2018-06-18 | 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 | 2018-05-04 | 2018-06-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-04 | 2018-06-18 | 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 | 2018-05-04 | 2018-06-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-04 | 2018-06-18 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-04-18 | 2017-06-03 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-04-18 | 2017-06-03 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-04-18 | 2017-06-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-04-18 | 2017-06-03 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-18 | 2017-06-03 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-04-18 | 2017-06-03 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-04-18 | 2017-06-03 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-04-18 | 2017-06-03 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-18 | 2017-06-03 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-04-18 | 2017-06-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-04-18 | 2017-06-03 | 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 | 2017-04-18 | 2017-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-04-18 | 2017-05-26 | N |
