Deficiency Records for Wayne Woodlands Manor
Updated as of May 01, 2024
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Deficiency Records for Wayne Woodlands Manor
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.
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 |
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