Deficiency Records for Woodlands Place Rehabilitation Suites
Updated as of March 01, 2024
A list of the most recent deficiencies for Woodlands Place Rehabilitation Suites. 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 safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-16 | 2023-12-16 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-11-16 | 2023-12-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-16 | 2023-12-16 | 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 | 2023-11-16 | 2023-12-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-16 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-16 | 2023-12-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-16 | 2023-12-16 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-16 | 2023-12-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-11 | 2023-07-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-06 | 2023-07-07 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-21 | 2022-10-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-22 | 2022-10-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-22 | 2022-10-21 | 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 | 2022-09-21 | 2022-10-17 | 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 | 2022-09-22 | 2022-10-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-22 | 2022-09-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-10 | 2021-12-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-08-03 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-15 | 2021-08-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-04 | 2021-06-14 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-06-01 | 2021-06-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-01 | 2021-06-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-01 | 2021-06-10 | Y |
| 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 | 2021-06-01 | 2021-06-10 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-06-01 | 2021-06-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-01 | 2021-06-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-02 | 2021-04-09 | Y |
