Inspection visit
Inspection
Citations
35 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.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0009GeneralS&S Fpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0018GeneralS&S Fpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0020GeneralS&S Fpotential for harm
Establish policies and procedures including evacuation.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0023GeneralS&S Fpotential for harm
Establish policies and procedures for medical documentation.
- 0024GeneralS&S Fpotential for harm
Establish policies and procedures for volunteers.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0032GeneralS&S Fpotential for harm
Provide primary/alternate means for communication.
- 0033GeneralS&S Fpotential for harm
Establish methods for sharing information.
- 0034GeneralS&S Fpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0346GeneralS&S Fpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the April 20, 2023 survey of WOODLAND CONVALESCENT CENTER?
This was a inspection survey of WOODLAND CONVALESCENT CENTER on April 20, 2023. The surveyor cited 35 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WOODLAND CONVALESCENT CENTER on April 20, 2023?
Yes, 35 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop a communication plan."
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.