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Deficiency Records for Embassy of Woodland Park
A list of the most recent deficiencies for Embassy of Woodland Park. 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 Embassy of Woodland Park. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-04-30 | 2024-05-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-30 | 2024-05-29 | 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 | 2024-01-29 | 2024-02-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-30 | 2024-01-24 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-30 | 2024-01-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-30 | 2024-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-30 | 2024-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | 2024-01-24 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-11-30 | 2024-01-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-30 | 2024-01-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-30 | 2024-01-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-30 | 2024-01-24 | 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 | 2023-11-30 | 2024-01-24 | N |
| 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 | 2023-11-30 | 2024-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2024-01-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-30 | 2024-01-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-30 | 2024-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2024-01-24 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-30 | 2024-01-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-30 | 2024-01-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-30 | 2024-01-24 | Y |
| 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 | 2023-11-20 | 2024-01-19 | 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 | 2023-11-20 | 2024-01-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-20 | 2024-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-20 | 2024-01-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-20 | 2024-01-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-20 | 2024-01-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-20 | 2024-01-19 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-11-20 | 2024-01-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-20 | 2024-01-19 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-01-19 | 2023-04-05 | 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 | 2023-01-19 | 2023-04-05 | 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 | 2023-01-19 | 2023-04-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-19 | 2023-04-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-01-19 | 2023-04-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-19 | 2023-04-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-19 | 2023-04-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-19 | 2023-04-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-11 | 2023-02-15 | 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 | 2023-01-11 | 2023-02-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-11 | 2023-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-11 | 2023-02-15 | 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 | 2023-01-11 | 2023-02-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-11 | 2023-02-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-11 | 2023-02-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-11 | 2023-02-15 | 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 | 2023-01-11 | 2023-02-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-11 | 2023-02-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-01-11 | 2023-02-15 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-01-11 | 2023-02-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-11 | 2023-02-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-11 | 2023-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-02-15 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-01-19 | 2023-02-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-19 | 2023-02-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-01-19 | 2023-02-15 | N |
| Meet other general requirements. | Fire Safety | 2023-01-19 | 2023-02-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-19 | 2023-02-15 | 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 | 2023-01-19 | 2023-02-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-01-19 | 2023-02-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-19 | 2023-02-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-19 | 2023-02-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-01-19 | 2023-02-15 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-01-19 | 2023-02-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-01-19 | 2023-02-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-22 | 2023-02-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-22 | 2023-02-08 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-01-27 | 2022-03-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-27 | 2022-03-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-01-27 | 2022-03-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-27 | 2022-03-08 | 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 | 2022-01-27 | 2022-03-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-27 | 2022-03-08 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-01-27 | 2022-03-08 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-01-27 | 2022-03-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-27 | 2022-03-08 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-01-27 | 2022-03-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-01-27 | 2022-03-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-03-08 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-25 | 2022-02-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-25 | 2022-02-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-25 | 2022-02-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-01-25 | 2022-02-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-25 | 2022-02-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-25 | 2022-02-22 | N |
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