A list of the most recent deficiencies for Woodland Convalescent Center. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-27 | 2023-11-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-20 | 2023-06-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-20 | 2023-06-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-20 | 2023-06-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-20 | 2023-06-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Develop a communication plan. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Establish methods for sharing information. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-20 | 2023-05-17 | 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 | 2023-04-20 | 2023-05-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-20 | 2023-05-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-20 | 2023-05-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-20 | 2023-05-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-20 | 2023-05-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-20 | 2023-05-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-20 | 2023-05-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-20 | 2023-05-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-20 | 2023-05-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-20 | 2023-05-08 | N |
| 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 | 2022-01-13 | 2022-03-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-13 | 2022-03-14 | 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 | 2022-01-13 | 2022-03-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-01-13 | 2022-03-14 | 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 | 2022-01-13 | 2022-03-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-13 | 2022-03-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-13 | 2022-03-14 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-01-13 | 2022-03-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-13 | 2022-03-14 | 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 | 2022-01-13 | 2022-03-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-13 | 2022-03-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-13 | 2022-03-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-13 | 2022-03-14 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-05 | 2022-01-06 | 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 | 2022-01-05 | 2022-01-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-01-05 | 2022-01-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-05 | 2022-01-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-09 | 2019-09-20 | N |
| 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 | 2019-08-09 | 2019-09-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-09 | 2019-09-20 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-08-09 | 2019-09-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-09 | 2019-09-20 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-09 | 2019-09-20 | 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 | 2019-08-09 | 2019-09-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-09 | 2019-09-20 | 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 | 2019-08-09 | 2019-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-09 | 2019-09-20 | 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 | 2019-08-09 | 2019-09-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-09 | 2019-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-09 | 2019-09-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-09 | 2019-09-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-09 | 2019-09-20 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-08-09 | 2019-09-20 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-08-09 | 2019-09-20 | N |
| Post nurse staffing information every day. | Health | 2019-08-09 | 2019-09-20 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-08-09 | 2019-09-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-09 | 2019-09-20 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2019-08-09 | 2019-09-20 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-08-09 | 2019-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-09 | 2019-09-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-08-09 | 2019-09-20 | 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 | 2019-08-09 | 2019-09-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-08-06 | 2019-09-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-08-06 | 2019-09-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-08-06 | 2019-09-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-06 | 2019-09-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-06 | 2019-08-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-06 | 2019-08-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-06 | 2019-08-15 | N |
