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Deficiency Records for Waldorf Center
A list of the most recent deficiencies for Waldorf Center. 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 Waldorf Center. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2024-08-19 | 2024-12-17 | N |
| Meet other general requirements. | Fire Safety | 2024-08-19 | 2024-12-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-19 | 2024-12-17 | 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 | 2024-08-19 | 2024-12-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-19 | 2024-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-19 | 2024-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-19 | 2024-12-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-08-19 | 2024-12-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-08-19 | 2024-11-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-20 | 2024-10-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-08-20 | 2024-10-15 | 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 | 2024-08-20 | 2024-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-20 | 2024-10-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-20 | 2024-10-15 | Y |
| Provide appropriate foot care. | Health | 2024-08-20 | 2024-10-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-20 | 2024-10-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-20 | 2024-10-15 | 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 | 2024-08-20 | 2024-10-15 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2024-08-20 | 2024-10-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-08-20 | 2024-10-15 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-08-20 | 2024-10-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-08-20 | 2024-10-15 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-08-20 | 2024-10-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-20 | 2024-10-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-08-20 | 2024-10-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-20 | 2024-10-15 | 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 | 2024-08-20 | 2024-10-15 | 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 | 2024-08-20 | 2024-10-15 | 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 | 2024-08-20 | 2024-10-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-20 | 2024-10-15 | N |
| Dispose of garbage and refuse properly. | Health | 2024-08-20 | 2024-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-20 | 2024-10-15 | 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 | 2024-08-20 | 2024-10-15 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-06-11 | 2019-07-29 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-06-11 | 2019-07-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-11 | 2019-07-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-11 | 2019-07-29 | N |
| Meet other general requirements. | Fire Safety | 2019-07-10 | 2019-07-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-10 | 2019-07-29 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-04-17 | 2018-06-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-17 | 2018-06-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-04-17 | 2018-06-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-02-27 | 2018-04-13 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-02-27 | 2018-04-13 | N |
| 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 | 2018-02-27 | 2018-04-13 | 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 | 2018-02-27 | 2018-04-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-27 | 2018-04-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-02-27 | 2018-04-13 | N |
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