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Deficiency Records for St Therese of Woodbury LLC
A list of the most recent deficiencies for St Therese of Woodbury LLC. 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 St Therese of Woodbury LLC. 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-05-23 | 2024-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-23 | 2024-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-23 | 2024-06-25 | 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 | 2024-05-23 | 2024-06-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-23 | 2024-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-23 | 2024-06-25 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-05-23 | 2024-06-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-05-23 | 2024-06-25 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-05-23 | 2024-06-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-22 | 2024-06-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-22 | 2024-06-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-22 | 2024-06-25 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-05-22 | 2024-06-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-11 | 2023-11-13 | Y |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-07-26 | 2023-09-26 | 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 | 2023-07-27 | 2023-09-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-27 | 2023-09-21 | 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 | 2023-07-27 | 2023-09-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-07-27 | 2023-09-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-26 | 2023-09-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-26 | 2023-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-26 | 2023-09-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-26 | 2023-09-01 | 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 | 2023-07-10 | 2023-08-30 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-26 | 2023-08-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-26 | 2023-08-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-26 | 2023-08-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-13 | 2023-08-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-13 | 2023-08-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-13 | 2023-01-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-13 | 2023-01-31 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-02 | 2022-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-02 | 2022-04-29 | N |
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