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Deficiency Records for Oakland Manor

A list of the most recent deficiencies for Oakland Manor. 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 Oakland Manor. 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?
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-04-22 2024-05-14 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-04-22 2024-05-14 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2024-04-22 2024-05-14 Y
Provide and implement an infection prevention and control program. Health 2024-04-22 2024-05-14 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-08-31 2023-09-28 N
Ensure each resident receives an accurate assessment. Health 2023-08-31 2023-09-28 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2023-08-31 2023-09-28 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 2023-08-31 2023-09-28 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-31 2023-09-28 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 2023-08-31 2023-09-28 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-08-31 2023-09-28 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2023-08-31 2023-09-28 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2023-08-31 2023-09-28 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-08-31 2023-09-28 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 2023-08-31 2023-09-28 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2023-08-31 2023-09-28 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-08-31 2023-09-28 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-08-31 2023-09-28 N
Provide and implement an infection prevention and control program. Health 2023-08-31 2023-09-28 N
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2023-08-31 2023-09-28 Y
Develop a communication plan. Fire Safety 2023-09-05 2023-09-06 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 2023-09-05 2023-09-06 N
Install proper backup exit lighting. Fire Safety 2023-09-05 2023-09-06 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-09-05 2023-09-06 N
Have properly located and lighted "Exit" signs. Fire Safety 2023-09-05 2023-09-06 N
Provide properly protected cooking facilities. Fire Safety 2023-09-05 2023-09-06 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-09-05 2023-09-06 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-09-05 2023-09-06 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-09-05 2023-09-06 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-09-05 2023-09-06 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-09-05 2023-09-06 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-09-05 2023-09-06 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-09-05 2023-09-06 N
Meet requirements for the use and maintenance of medical gas equipment. Fire Safety 2023-09-05 2023-09-06 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-09-05 2023-09-05 N
Protect each resident from the wrongful use of the resident's belongings or money. Health 2023-07-11 2023-07-20 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-06-03 2022-06-24 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-06-03 2022-06-24 Y
Ensure each resident receives an accurate assessment. Health 2022-06-03 2022-06-24 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-06-03 2022-06-24 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-06-03 2022-06-24 Y
Provide appropriate foot care. Health 2022-06-03 2022-06-24 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-06-03 2022-06-24 Y
Provide enough food/fluids to maintain a resident's health. Health 2022-06-03 2022-06-24 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-06-03 2022-06-24 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 2022-06-03 2022-06-24 Y
Post nurse staffing information every day. Health 2022-06-03 2022-06-24 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 2022-06-03 2022-06-24 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-06-03 2022-06-24 Y
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2022-06-03 2022-06-24 Y
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2022-06-03 2022-06-24 Y
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2022-06-03 2022-06-24 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-06-03 2022-06-24 Y
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2022-06-06 2022-06-20 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2022-06-06 2022-06-20 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2022-06-06 2022-06-20 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-06-06 2022-06-20 N
Provide a written emergency evacuation plan. Fire Safety 2022-06-06 2022-06-20 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-06-06 2022-06-20 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-06-06 2022-06-20 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2022-06-06 2022-06-20 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-06-06 2022-06-20 N
Meet requirements for the use and maintenance of medical gas equipment. Fire Safety 2022-06-06 2022-06-20 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-06-06 2022-06-06 N
Establish roles under a Waiver declared by secretary. Fire Safety 2022-06-06 2022-06-06 N
Provide and implement an infection prevention and control program. Health 2022-03-25 2022-04-18 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-12-20 2022-04-18 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-12-20 2022-04-18 Y
Provide and implement an infection prevention and control program. Health 2021-12-20 2022-04-18 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-12-20 2021-12-29 Y
Ensure each resident receives an accurate assessment. Health 2021-12-20 2021-12-29 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2021-12-20 2021-12-29 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-12-20 2021-12-29 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-12-20 2021-12-29 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-12-20 2021-12-29 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 2021-12-20 2021-12-29 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 2021-12-20 2021-12-29 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 2021-12-20 2021-12-29 Y
Ensure medication error rates are not 5 percent or greater. Health 2021-12-20 2021-12-29 Y
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2021-12-20 2021-12-29 Y
Install corridor and hallway doors that block smoke. Fire Safety 2020-02-13 2020-06-01 N
Conduct testing and exercise requirements. Fire Safety 2020-02-13 2020-03-13 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 2020-02-06 2020-03-11 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2020-02-06 2020-03-11 N
Ensure each resident receives an accurate assessment. Health 2020-02-06 2020-03-11 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2020-02-06 2020-03-11 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-02-06 2020-03-11 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2020-02-06 2020-03-11 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2020-02-06 2020-03-11 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2020-02-06 2020-03-11 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2020-02-06 2020-03-11 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 2020-02-06 2020-03-11 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-02-06 2020-03-11 N
Provide and implement an infection prevention and control program. Health 2020-02-06 2020-03-11 N
Establish roles under a Waiver declared by secretary. Fire Safety 2020-02-13 2020-02-28 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2020-02-13 2020-02-28 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2020-02-13 2020-02-28 N
Ensure proper usage of power strips and extension cords. Fire Safety 2020-02-13 2020-02-28 N
Have simulated fire drills held at unexpected times. Fire Safety 2020-02-13 2020-02-18 N
Use approved construction type or materials. Fire Safety 2020-02-13 2020-02-14 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 2020-02-13 2020-02-14 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 2020-02-13 2020-02-13 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2020-02-13 2020-02-13 N
Have proper medical gas storage and administration areas. Fire Safety 2020-02-13 2020-02-13 N

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