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Deficiency Records for Silver Oak Nursing and Rehabilitation Center LLC
A list of the most recent deficiencies for Silver Oak Nursing and Rehabilitation Center 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 Silver Oak Nursing and Rehabilitation Center 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-21 | 2024-09-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-30 | 2024-05-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-30 | 2024-05-17 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-22 | 2024-04-15 | N |
| Use approved construction type or materials. | Fire Safety | 2024-02-27 | 2024-03-27 | 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 | 2024-02-27 | 2024-03-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-27 | 2024-03-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-27 | 2024-03-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-27 | 2024-03-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-27 | 2024-03-27 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-02-27 | 2024-03-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-22 | 2024-03-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-22 | 2024-03-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-22 | 2024-03-22 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2024-02-22 | 2024-03-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-22 | 2024-03-22 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-02-22 | 2024-03-22 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-02-22 | 2024-03-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-22 | 2024-03-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-22 | 2024-03-22 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-02-22 | 2024-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-22 | 2024-02-22 | 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 | 2023-10-05 | 2023-11-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-05 | 2023-11-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-05 | 2023-11-05 | 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 | 2023-10-05 | 2023-11-05 | Y |
| 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 | 2023-10-05 | 2023-11-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-05 | 2023-10-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-05 | 2023-10-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-08 | 2023-07-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-08 | 2023-07-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-08 | 2023-07-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-08 | 2023-07-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-08 | 2023-07-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-07-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-07-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-08 | 2023-07-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-29 | 2023-03-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-31 | 2023-03-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-31 | 2023-03-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-31 | 2023-03-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-15 | 2023-01-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-15 | 2023-01-19 | Y |
| 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 | 2022-12-15 | 2023-01-19 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-15 | 2023-01-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-15 | 2023-01-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-15 | 2023-01-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-15 | 2023-01-19 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-12-15 | 2023-01-19 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-15 | 2023-01-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-15 | 2023-01-19 | Y |
| 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 | 2022-12-15 | 2023-01-19 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-14 | 2023-01-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-14 | 2023-01-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-12-14 | 2023-01-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-14 | 2022-12-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-14 | 2022-12-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-14 | 2022-12-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-14 | 2022-12-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-14 | 2022-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-14 | 2022-12-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-07 | 2022-10-15 | 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 | 2022-09-07 | 2022-10-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-07 | 2022-10-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-07 | 2022-10-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-07 | 2022-10-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-07 | 2022-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-07 | 2022-10-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-07 | 2022-10-15 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-09-07 | 2022-10-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-14 | 2022-08-14 | 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 | 2022-07-14 | 2022-08-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-14 | 2022-08-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-14 | 2022-08-14 | Y |
| 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 | 2022-07-14 | 2022-08-14 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-05-17 | 2022-06-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-17 | 2022-06-17 | Y |
| 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 | 2022-05-17 | 2022-06-17 | Y |
| 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 | 2021-12-28 | 2022-03-23 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-12-28 | 2022-03-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-28 | 2022-03-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-28 | 2022-03-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-12-28 | 2022-03-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-28 | 2022-03-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-28 | 2022-03-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-28 | 2022-03-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-28 | 2022-01-27 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-12-28 | 2022-01-27 | 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 | 2021-12-28 | 2022-01-27 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-12-28 | 2022-01-27 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-12-28 | 2022-01-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-28 | 2022-01-27 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-12-28 | 2022-01-27 | 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 | 2021-12-28 | 2022-01-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-28 | 2022-01-27 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-12-28 | 2022-01-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-12-28 | 2022-01-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-28 | 2022-01-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-28 | 2022-01-27 | Y |
| 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 | 2021-12-28 | 2022-01-27 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-28 | 2022-01-27 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-12-28 | 2022-01-27 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-12-28 | 2022-01-27 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-14 | 2022-01-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-12-14 | 2022-01-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-14 | 2021-12-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-14 | 2021-12-14 | N |
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