Inspection visit
Inspection
Citations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0018GeneralS&S Dpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0032GeneralS&S Fpotential for harm
Provide primary/alternate means for communication.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
F554 - The right to self-administer medications if the interdisciplinary team, as
Allow residents to self-administer drugs if determined clinically appropriate.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F688 - Mobility
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.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0541GeneralS&S Fpotential for harm
Install properly constructed and protected linen or trash chutes.
FAQ · About this visit
Common questions about this visit
What happened during the May 23, 2024 survey of St Therese Of Woodbury Llc?
This was a inspection survey of St Therese Of Woodbury Llc on May 23, 2024. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at St Therese Of Woodbury Llc on May 23, 2024?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish procedures for tracking staff and patients during an emergency."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.