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Deficiency Records for Woodlyn Heights Healthcare Center
A list of the most recent deficiencies for Woodlyn Heights Healthcare 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 Woodlyn Heights Healthcare 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? |
|---|---|---|---|---|
| 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 | 2024-07-17 | 2024-08-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-17 | 2024-08-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-17 | 2024-08-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-17 | 2024-08-11 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-07-17 | 2024-08-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-17 | 2024-08-11 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-13 | 2024-05-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-03-14 | 2024-04-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-14 | 2024-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-14 | 2024-04-07 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-03-14 | 2024-04-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-14 | 2024-04-07 | N |
| Post nurse staffing information every day. | Health | 2024-03-14 | 2024-04-07 | 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 | 2024-03-14 | 2024-04-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-14 | 2024-04-07 | N |
| Provide or obtain dental services for each resident. | Health | 2024-03-14 | 2024-04-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-14 | 2024-04-07 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-03-14 | 2024-04-07 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-03-14 | 2024-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-14 | 2024-04-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-03-14 | 2024-04-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-05 | 2024-03-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-06 | 2023-09-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-29 | 2023-07-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-29 | 2023-07-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-01 | 2023-07-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-01 | 2023-07-06 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-06-01 | 2023-07-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-01 | 2023-07-06 | 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 | 2023-06-01 | 2023-07-06 | N |
| Post nurse staffing information every day. | Health | 2023-06-01 | 2023-07-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-01 | 2023-07-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-01 | 2023-07-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-01 | 2023-06-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-04-19 | 2023-05-06 | 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 | 2023-03-15 | 2023-03-02 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-10 | 2022-12-15 | 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 | 2022-09-12 | 2022-09-20 | 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 | 2022-07-13 | 2022-08-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-13 | 2022-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-13 | 2022-08-01 | Y |
| 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 | 2022-07-13 | 2022-08-01 | Y |
| 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 | 2022-07-13 | 2022-08-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-13 | 2022-08-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-13 | 2022-08-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-17 | 2022-07-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-09 | 2022-07-01 | Y |
| 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 | 2022-06-09 | 2022-07-01 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-19 | 2022-05-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-25 | 2022-03-31 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-25 | 2022-03-31 | 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 | 2022-02-25 | 2022-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-25 | 2022-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-25 | 2022-03-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-25 | 2022-03-31 | 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 | 2022-02-25 | 2022-03-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-25 | 2022-03-31 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-02-25 | 2022-03-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-25 | 2022-03-31 | 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 | 2022-02-25 | 2022-03-31 | 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 | 2022-02-25 | 2022-03-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-25 | 2022-03-31 | 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 | 2022-02-25 | 2022-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-25 | 2022-03-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-25 | 2022-03-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-25 | 2022-03-31 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-25 | 2022-03-31 | Y |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-02-25 | 2022-03-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-02-25 | 2022-03-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-25 | 2022-03-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-23 | 2022-03-31 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-02-23 | 2022-03-31 | 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 | 2022-02-23 | 2022-03-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-23 | 2022-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-23 | 2022-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-23 | 2022-03-31 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-02-23 | 2022-03-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-23 | 2022-03-31 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-02-23 | 2022-03-31 | 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 | 2021-12-16 | 2022-01-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-20 | 2021-11-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-20 | 2021-11-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-20 | 2021-11-15 | Y |
| 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 | 2021-10-20 | 2021-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-20 | 2021-11-15 | Y |
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