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Deficiency Records for White Oak Post Acute Care
A list of the most recent deficiencies for White Oak Post Acute Care. 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 White Oak Post Acute Care. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-07-18 | 2024-08-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-18 | 2024-08-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-18 | 2024-08-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-18 | 2024-08-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-18 | 2024-08-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-10 | 2024-07-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-10 | 2024-07-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-10 | 2024-07-01 | Y |
| 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 | 2024-06-10 | 2024-07-01 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-06-10 | 2024-07-01 | 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 | 2024-06-10 | 2024-07-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-10 | 2024-07-01 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-06-10 | 2024-07-01 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-06-10 | 2024-07-01 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-06-10 | 2024-07-01 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-06-10 | 2024-07-01 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-06-10 | 2024-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-10 | 2024-06-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-16 | 2024-04-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-04-16 | 2024-04-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-16 | 2024-04-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-14 | 2024-01-25 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-29 | 2024-01-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-09-29 | N |
| Dispose of garbage and refuse properly. | Health | 2023-08-17 | 2023-09-29 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-08-17 | 2023-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-09-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-08-17 | 2023-09-29 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-08-17 | 2023-09-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-17 | 2023-09-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-17 | 2023-09-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-17 | 2023-09-29 | 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 | 2023-08-17 | 2023-09-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-17 | 2023-09-29 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-17 | 2023-09-29 | 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 | 2023-08-17 | 2023-09-29 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-08-17 | 2023-09-29 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-08-17 | 2023-09-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-17 | 2023-09-29 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-08-17 | 2023-09-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-17 | 2023-09-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-14 | 2023-09-26 | 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 | 2023-08-14 | 2023-08-14 | 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 | 2023-01-12 | 2023-02-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-12 | 2023-02-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-02-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-16 | 2022-10-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-16 | 2022-10-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-09-16 | 2022-10-24 | 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 | 2022-09-16 | 2022-10-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-16 | 2022-10-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-16 | 2022-10-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-16 | 2022-10-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-16 | 2022-10-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-16 | 2022-10-24 | 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 | 2022-09-16 | 2022-10-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-16 | 2022-10-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-16 | 2022-10-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-16 | 2022-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-16 | 2022-10-24 | N |
| Keep all essential equipment working safely. | Health | 2022-09-16 | 2022-10-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-24 | 2022-05-06 | Y |
| Help the resident with transportation to and from laboratory services outside of the facility. | Health | 2022-03-24 | 2022-05-06 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-09-20 | Not Fixed | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-09-20 | Not Fixed | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-09-20 | Not Fixed | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-20 | Not Fixed | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-09-20 | Not Fixed | N |
| 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 | 2024-09-20 | Not Fixed | N |
| Post nurse staffing information every day. | Health | 2024-09-20 | Not Fixed | 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 | 2024-09-20 | Not Fixed | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-09-20 | Not Fixed | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-20 | Not Fixed | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-09-20 | Not Fixed | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2024-09-20 | Not Fixed | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-09-20 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-20 | Not Fixed | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-09-20 | Not Fixed | 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 | 2024-09-20 | Not Fixed | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-20 | Not Fixed | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-20 | Not Fixed | 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 | 2024-09-20 | Not Fixed | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2024-09-17 | Not Fixed | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-17 | Not Fixed | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-09-17 | Not Fixed | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-09-17 | Not Fixed | N |
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