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Deficiency Records for Althea Woodland Nursing Home

A list of the most recent deficiencies for Althea Woodland Nursing Home. 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 Althea Woodland Nursing Home. 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?
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 2024-08-02 2024-10-22 Y
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Health 2024-08-02 2024-10-22 Y
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2024-08-02 2024-10-22 Y
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2021-04-09 2021-06-07 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-04-09 2021-06-07 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 2021-04-09 2021-06-07 N
Establish emergency prep training and testing. Fire Safety 2021-04-07 2021-06-06 N
Establish staff and initial training requirements. Fire Safety 2021-04-07 2021-06-06 N
Conduct testing and exercise requirements. Fire Safety 2021-04-07 2021-06-06 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2021-04-07 2021-06-06 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-04-07 2021-06-06 N
Meet requirements for the use of electrical equipment. Fire Safety 2021-04-07 2021-06-06 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-07-22 2019-09-19 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-07-22 2019-09-19 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-07-11 2019-09-10 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 2019-07-11 2019-09-10 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 2019-07-11 2019-09-10 N
Observe each nurse aide's job performance and give regular training. Health 2019-07-11 2019-09-10 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 2019-07-11 2019-09-10 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 2019-07-11 2019-09-10 N
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Health 2019-07-11 2019-09-10 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-07-11 2019-09-10 N
Provide and implement an infection prevention and control program. Health 2019-07-11 2019-09-10 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2019-07-11 2019-09-10 N
Construct fire resistant interior walls. Fire Safety 2019-07-22 2019-08-21 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-07-22 2019-08-21 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2019-07-22 2019-07-31 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2019-07-22 2019-07-31 N
Have a battery powered remote alarm panel in a location accessible by operating personnel. Fire Safety 2018-06-21 2018-10-30 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 2018-06-21 2018-09-12 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2018-06-21 2018-09-12 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2018-06-21 2018-09-12 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2018-06-21 2018-09-12 N
Have proper medical gas storage and administration areas. Fire Safety 2018-06-21 2018-09-12 N
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Health 2018-06-22 2018-08-21 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 2018-06-22 2018-08-21 N
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. Health 2018-06-22 2018-08-21 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2018-06-22 2018-08-21 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 2018-06-22 2018-08-21 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2018-06-22 2018-08-21 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2018-06-22 2018-08-21 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2018-06-22 2018-08-21 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2018-06-22 2018-08-21 N
Provide activities to meet all resident's needs. Health 2018-06-22 2018-08-21 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2018-06-22 2018-08-21 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2018-06-22 2018-08-21 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 2018-06-22 2018-08-21 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2018-06-22 2018-08-21 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2018-06-22 2018-08-21 N
Provide and implement an infection prevention and control program. Health 2018-06-22 2018-08-21 N

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