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Deficiency Records for Woodlands The
A list of the most recent deficiencies for Woodlands The. 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 Woodlands The. 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? |
|---|---|---|---|---|
| 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 | 2024-05-16 | 2024-06-04 | Y |
| 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 | 2024-02-23 | 2024-03-23 | 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 | 2024-02-23 | 2024-03-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-23 | 2024-03-23 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-02-23 | 2024-03-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-23 | 2024-03-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-23 | 2024-03-23 | 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 | 2024-02-23 | 2024-03-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-23 | 2024-03-23 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-07 | 2024-03-23 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-03-07 | 2024-03-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-03-07 | 2024-03-23 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-03-07 | 2024-03-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-07 | 2024-03-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-03 | 2023-11-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-24 | 2023-09-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-24 | 2023-09-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-17 | 2023-04-07 | Y |
| 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 | 2023-03-17 | 2023-04-07 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-06 | 2023-03-09 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-02-06 | 2023-03-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-06 | 2023-03-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-06 | 2023-03-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-06 | 2023-03-09 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-02-06 | 2023-03-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-06 | 2023-03-09 | 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 | 2023-01-30 | 2023-03-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-30 | 2023-03-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-30 | 2023-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-30 | 2023-03-03 | N |
| Keep all essential equipment working safely. | Health | 2023-01-30 | 2023-03-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-02 | 2022-12-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-02 | 2022-12-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-02 | 2022-12-20 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-02 | 2022-12-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-02 | 2022-03-18 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Develop a communication plan. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-01-13 | 2022-01-28 | 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 | 2022-01-13 | 2022-01-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-13 | 2022-01-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-01-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-21 | 2022-01-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-08 | 2021-10-15 | Y |
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