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Deficiency Records for White Oak Rehabilitation and Nursing Center
A list of the most recent deficiencies for White Oak Rehabilitation and Nursing Center. 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 Rehabilitation and Nursing Center. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-18 | 2024-02-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-18 | 2024-02-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-18 | 2024-02-29 | 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 | 2024-01-18 | 2024-02-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-18 | 2024-02-29 | 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 | 2024-01-18 | 2024-02-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-18 | 2024-02-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-18 | 2024-02-29 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-01-18 | 2024-02-29 | 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 | 2024-01-18 | 2024-02-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-18 | 2024-02-29 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-18 | 2024-02-29 | Y |
| Keep all essential equipment working safely. | Health | 2024-01-18 | 2024-02-29 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-18 | 2024-02-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-11 | 2023-08-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-19 | 2023-04-05 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-12-19 | 2023-03-01 | 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 | 2022-12-19 | 2023-03-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-19 | 2023-03-01 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2022-12-19 | 2023-03-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-28 | 2021-07-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-28 | 2021-07-26 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-05-28 | 2021-07-26 | 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 | 2021-05-28 | 2021-07-26 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-05-28 | 2021-07-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-28 | 2021-07-26 | N |
| Respond appropriately to all alleged violations. | Health | 2021-05-28 | 2021-07-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-28 | 2021-07-26 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-05-28 | 2021-07-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-28 | 2021-07-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-05-28 | 2021-07-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-05-28 | 2021-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-28 | 2021-07-26 | 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 | 2021-05-28 | 2021-07-26 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-05-28 | 2021-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-28 | 2021-07-26 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-05-28 | 2021-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-28 | 2021-07-26 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-05-28 | 2021-07-26 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-05-28 | 2021-07-26 | 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 | 2021-05-28 | 2021-07-26 | 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 | 2021-05-28 | 2021-07-26 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-05-28 | 2021-07-26 | N |
| Post nurse staffing information every day. | Health | 2021-05-28 | 2021-07-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-28 | 2021-07-26 | 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 | 2021-05-28 | 2021-07-26 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-05-28 | 2021-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-28 | 2021-07-26 | N |
| Dispose of garbage and refuse properly. | Health | 2021-05-28 | 2021-07-26 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-05-28 | 2021-07-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-28 | 2021-07-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-05-28 | 2021-07-26 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-05-28 | 2021-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-28 | 2021-07-26 | N |
| Keep all essential equipment working safely. | Health | 2021-05-28 | 2021-07-26 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2021-05-28 | 2021-07-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-24 | 2021-06-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-24 | 2021-06-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-24 | 2021-06-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-05-24 | 2021-06-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-24 | 2021-06-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-10-24 | 2018-12-08 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-10-24 | 2018-12-08 | 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 | 2018-10-24 | 2018-10-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-24 | 2018-10-29 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-07-08 | 2017-09-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-07-08 | 2017-09-06 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-07-08 | 2017-09-06 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-07-08 | 2017-09-06 | N |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-07-08 | 2017-09-06 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-07-08 | 2017-09-06 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-07-08 | 2017-09-06 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2017-07-08 | 2017-09-06 | N |
| Provide housekeeping and maintenance services. | Health | 2017-07-08 | 2017-09-06 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-07-08 | 2017-09-06 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-08 | 2017-09-06 | N |
| Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. | Health | 2017-07-08 | 2017-09-06 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2017-07-08 | 2017-09-06 | N |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-07-08 | 2017-09-06 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-07-08 | 2017-09-06 | N |
| Operate and provide services according to Federal, State, and local laws and professional standards. | Health | 2017-07-08 | 2017-09-06 | N |
| 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 | 2017-07-08 | 2017-09-06 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2017-07-08 | 2017-09-06 | N |
| Keep clinical record information safe. | Health | 2017-07-08 | 2017-09-06 | 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 | 2017-06-28 | 2017-08-11 | 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 | 2017-06-28 | 2017-08-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-28 | 2017-08-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-06-28 | 2017-08-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-06-28 | 2017-08-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-06-28 | 2017-08-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2017-06-28 | 2017-08-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-06-28 | 2017-08-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-06-28 | 2017-08-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-06-28 | 2017-08-11 | N |
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