Deficiency Records for Woodland Manor Nursing and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Woodland Manor Nursing and Rehabilitation. 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 each resident receives an accurate assessment. | Health | 2023-11-09 | 2023-12-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-13 | 2023-04-21 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-14 | 2022-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-14 | 2022-10-15 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-09-28 | 2022-10-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-28 | 2022-09-30 | 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 | 2022-09-26 | 2022-09-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-26 | 2022-09-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-26 | 2022-09-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-14 | 2022-09-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-14 | 2022-09-17 | Y |
| 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 | 2022-09-14 | 2022-09-17 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-07-28 | 2022-08-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-28 | 2022-08-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-20 | 2022-07-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-20 | 2022-07-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-20 | 2022-07-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-20 | 2022-07-23 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-07-01 | 2022-07-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-01 | 2022-07-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-01 | 2022-07-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-06 | 2022-01-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-01 | 2022-01-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-06 | 2021-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-06 | 2021-12-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-06 | 2021-12-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-06 | 2021-12-30 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-12-06 | 2021-12-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-06 | 2021-12-30 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-12-06 | 2021-12-30 | 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 | 2021-10-21 | 2021-11-10 | Y |
| Provide or obtain dental services for each resident. | Health | 2021-10-21 | 2021-11-10 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-10-21 | 2021-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-21 | 2021-11-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-23 | 2021-08-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-23 | 2021-08-13 | 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 | 2021-07-23 | 2021-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-23 | 2021-08-13 | 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 | 2021-07-22 | 2021-08-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-22 | 2021-08-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-22 | 2021-08-13 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-07-22 | 2021-08-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-07-31 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-06-25 | 2019-07-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-25 | 2019-07-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-25 | 2019-07-18 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-06-25 | 2019-07-18 | N |
