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Deficiency Records for Woods Edge Rehab and Nursing
A list of the most recent deficiencies for Woods Edge Rehab and Nursing. 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 Woods Edge Rehab and Nursing. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-11 | 2024-10-28 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-06-07 | 2024-06-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-07 | 2024-06-25 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-06-07 | 2024-06-25 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-06-07 | 2024-06-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-06-07 | 2024-06-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-07 | 2024-06-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-26 | 2024-04-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-03-26 | 2024-04-17 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-11-08 | 2023-12-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-11 | 2023-08-31 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-23 | 2023-07-12 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-23 | 2023-07-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-09 | 2023-03-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-09 | 2023-03-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-09 | 2023-03-30 | N |
| Provide activities to meet all resident's needs. | Health | 2023-02-09 | 2023-03-30 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-09 | 2023-03-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-02-09 | 2023-03-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-09 | 2023-03-30 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-07 | 2023-03-30 | 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 | 2023-02-07 | 2023-03-30 | 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 | 2023-02-07 | 2023-03-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-07 | 2023-03-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-07 | 2022-08-05 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-01-07 | 2022-02-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-06-13 | 2019-08-02 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-06-13 | 2019-08-02 | 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 | 2019-06-13 | 2019-08-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-13 | 2019-08-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-13 | 2019-08-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-13 | 2019-08-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-13 | 2019-08-02 | 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 | 2019-06-13 | 2019-08-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-13 | 2019-08-02 | 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 | 2019-06-13 | 2019-08-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-13 | 2019-08-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-06-13 | 2019-08-02 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2019-06-13 | 2019-08-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-13 | 2019-08-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-13 | 2019-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-13 | 2019-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-13 | 2019-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-13 | 2019-08-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-17 | 2018-07-06 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-05-17 | 2018-07-06 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-05-17 | 2018-07-06 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2018-05-17 | 2018-07-06 | 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 | 2018-05-17 | 2018-07-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-05-17 | 2018-07-06 | 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 | 2018-05-17 | 2018-07-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-17 | 2018-07-06 | 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 | 2018-05-17 | 2018-07-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-17 | 2018-07-06 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-05-17 | 2018-07-06 | N |
| Post nurse staffing information every day. | Health | 2018-05-17 | 2018-07-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-17 | 2018-07-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-05-16 | 2018-07-06 | 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 | 2018-05-16 | 2018-07-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-05-16 | 2018-07-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-16 | 2018-07-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-16 | 2018-07-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-16 | 2018-07-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-05-16 | 2018-07-06 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-05-16 | 2018-07-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-05-16 | 2018-07-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-16 | 2018-07-06 | N |
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