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Deficiency Records for Woodcrest Post Acute and Rehabilitation

A list of the most recent deficiencies for Woodcrest Post Acute and Rehabilitation. 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 Woodcrest Post Acute 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?
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-08-12 2024-08-23 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 2024-07-23 2024-07-31 Y
Post nurse staffing information every day. Health 2024-07-15 2024-07-25 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-06-25 2024-07-16 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-06-25 2024-07-16 Y
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 2024-06-25 2024-07-16 Y
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. Health 2024-06-11 2024-07-03 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-05-24 2024-06-13 Y
Prepare residents for a safe transfer or discharge from the nursing home. Health 2024-04-26 2024-05-17 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-04-26 2024-05-17 Y
Give the resident's representative the ability to exercise the resident's rights. Health 2024-04-08 2024-04-17 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-03-14 2024-03-22 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-02-06 2024-02-13 Y
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 2024-01-23 2024-01-31 Y
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Health 2024-01-23 2024-01-31 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-10-28 2023-11-13 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-10-27 2023-11-08 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-09-19 2023-09-29 Y
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-09-14 2023-09-21 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-05-17 2023-06-02 Y
Provide enough food/fluids to maintain a resident's health. Health 2023-04-03 2023-04-13 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-02-10 2023-02-22 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-01-12 2023-01-29 Y
Provide or obtain dental services for each resident. Health 2022-10-27 2022-11-02 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-10-27 2022-11-02 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 2022-09-27 2022-10-07 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-09-27 2022-10-07 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-07-06 2022-07-18 Y
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2022-03-23 2022-04-04 Y
Provide emergency officials' contact information. Fire Safety 2021-09-28 2021-11-02 N
Use approved construction type or materials. Fire Safety 2021-09-28 2021-11-02 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2021-09-28 2021-11-02 N
Install an approved automatic sprinkler system. Fire Safety 2021-09-28 2021-11-02 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-09-28 2021-11-02 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2021-09-28 2021-11-02 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-09-28 2021-11-02 N
Have power receptacles that are properly grounded. Fire Safety 2021-09-28 2021-11-02 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-09-28 2021-11-02 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 2021-09-24 2021-10-29 N
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2021-09-24 2021-10-29 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-09-24 2021-10-29 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-09-24 2021-10-29 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-09-24 2021-10-29 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-09-24 2021-10-29 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 2021-09-24 2021-10-29 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-09-24 2021-10-29 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 2021-09-24 2021-10-29 N
Ensure medication error rates are not 5 percent or greater. Health 2021-09-24 2021-10-29 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 2021-09-24 2021-10-29 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2021-09-24 2021-10-29 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-09-24 2021-10-29 N
Provide and implement an infection prevention and control program. Health 2021-09-24 2021-10-29 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2021-09-24 2021-10-29 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2020-02-12 2020-06-12 N
Address subsistence needs for staff and patients. Fire Safety 2020-02-12 2020-06-12 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2020-02-12 2020-06-12 N
Establish policies and procedures including evacuation. Fire Safety 2020-02-12 2020-06-12 N
Establish policies and procedures for medical documentation. Fire Safety 2020-02-12 2020-06-12 N
Create arrangements with other facilities to receive patients. Fire Safety 2020-02-12 2020-06-12 N
List the names and contact information of those in the facility. Fire Safety 2020-02-12 2020-06-12 N
Provide emergency officials' contact information. Fire Safety 2020-02-12 2020-06-12 N
Provide family notifications of emergency plan. Fire Safety 2020-02-12 2020-06-12 N
Establish emergency prep training and testing. Fire Safety 2020-02-12 2020-06-12 N
Use approved construction type or materials. Fire Safety 2020-02-12 2020-06-12 N
Have properly located and lighted "Exit" signs. Fire Safety 2020-02-12 2020-06-12 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 2020-02-12 2020-06-12 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2020-02-12 2020-06-12 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2020-02-12 2020-06-12 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2020-02-12 2020-06-12 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2020-02-12 2020-06-12 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2020-02-12 2020-06-12 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2020-02-12 2020-06-12 N
Reasonably accommodate the needs and preferences of each resident. Health 2020-02-10 2020-03-12 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 2020-02-10 2020-03-12 N
Keep residents' personal and medical records private and confidential. Health 2020-02-10 2020-03-12 N
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2020-02-10 2020-03-12 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2020-02-10 2020-03-12 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-02-10 2020-03-12 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 2020-02-10 2020-03-12 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2020-02-10 2020-03-12 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2020-02-10 2020-03-12 N
Provide enough food/fluids to maintain a resident's health. Health 2020-02-10 2020-03-12 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 2020-02-10 2020-03-12 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 2020-02-10 2020-03-12 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2020-02-10 2020-03-12 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 2020-02-10 2020-03-12 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 2020-02-10 2020-03-12 N
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2020-02-10 2020-03-12 N
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2020-02-10 2020-03-12 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-02-10 2020-03-12 N
Have a policy regarding use and storage of foods brought to residents by family and other visitors. Health 2020-02-10 2020-03-12 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 2020-02-10 2020-03-12 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2020-02-10 2020-03-12 N
Provide and implement an infection prevention and control program. Health 2020-02-10 2020-03-12 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2020-02-10 2020-03-12 N
Create arrangements with other facilities to receive patients. Fire Safety 2019-04-16 2019-05-06 N
Conduct testing and exercise requirements. Fire Safety 2019-04-16 2019-05-06 N
Implement emergency and standby power systems. Fire Safety 2019-04-16 2019-05-06 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-04-16 2019-05-06 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2019-04-16 2019-05-06 N
Have proper medical gas storage and administration areas. Fire Safety 2019-04-16 2019-05-06 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2019-02-14 2019-04-11 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 2019-02-14 2019-04-11 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 2019-02-14 2019-04-11 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-02-14 2019-04-11 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 2019-02-14 2019-03-27 N
Assess the resident when there is a significant change in condition Health 2019-02-14 2019-03-27 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-02-14 2019-03-27 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 2019-02-14 2019-03-27 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-02-14 2019-03-27 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-02-14 2019-03-27 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 2019-02-14 2019-03-27 N
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2019-02-14 2019-03-27 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 2019-02-14 2019-03-27 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2019-02-14 2019-03-27 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2019-02-14 2019-03-27 N
Provide and implement an infection prevention and control program. Health 2019-02-14 2019-03-27 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2019-02-14 2019-03-27 N

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