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Deficiency Records for Oakridge Manor Nursing and Rehab Center LLC
A list of the most recent deficiencies for Oakridge Manor Nursing and Rehab 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 Oakridge Manor Nursing and Rehab 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? |
|---|---|---|---|---|
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-07-17 | 2024-08-05 | 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 | 2024-07-17 | 2024-08-05 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2024-04-26 | 2024-05-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-04-26 | 2024-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-26 | 2024-05-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-04-26 | 2024-05-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-24 | 2024-05-28 | N |
| 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 | 2024-04-24 | 2024-05-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-24 | 2024-05-28 | N |
| 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 | 2024-04-24 | 2024-05-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-24 | 2024-05-28 | 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 | 2024-04-24 | 2024-05-28 | 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 | 2024-04-24 | 2024-05-28 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-04-24 | 2024-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-24 | 2024-05-28 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-04-24 | 2024-05-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-24 | 2024-05-28 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-12-27 | 2024-01-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-27 | 2024-01-12 | Y |
| 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 | 2023-05-24 | 2023-06-30 | 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 | 2023-05-24 | 2023-06-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-24 | 2023-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-24 | 2023-06-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-24 | 2023-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-24 | 2023-06-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-24 | 2023-06-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-24 | 2023-06-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-18 | 2023-06-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-18 | 2023-06-28 | 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 | 2023-05-18 | 2023-06-28 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-18 | 2023-06-28 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-05-18 | 2023-06-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-05-18 | 2023-06-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-18 | 2023-06-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-18 | 2023-06-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-18 | 2023-06-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-18 | 2023-06-28 | 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 | 2023-05-18 | 2023-06-28 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-18 | 2023-06-28 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-05-18 | 2023-06-28 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-05-18 | 2023-06-28 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-05-18 | 2023-06-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-18 | 2023-06-28 | 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 | 2023-05-18 | 2023-06-28 | 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 | 2023-05-18 | 2023-06-28 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2023-05-18 | 2023-06-28 | N |
| Dispose of garbage and refuse properly. | Health | 2023-05-18 | 2023-06-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-18 | 2023-06-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-18 | 2023-06-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-18 | 2023-06-28 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-05-18 | 2023-06-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-02-08 | 2023-03-02 | 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 | 2023-02-08 | 2023-03-02 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-02-08 | 2023-03-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-09 | 2022-08-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-13 | 2022-08-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-13 | 2022-08-01 | N |
| 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 | 2022-04-13 | 2022-08-01 | 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 | 2022-04-13 | 2022-08-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-13 | 2022-08-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-13 | 2022-08-01 | N |
| 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 | 2022-04-13 | 2022-08-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-13 | 2022-08-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-18 | 2022-06-14 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-11 | 2022-06-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-11 | 2022-05-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-13 | 2022-05-24 | Y |
| Ensure a qualified health professional conducts resident assessments. | Health | 2022-04-13 | 2022-05-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-13 | 2022-05-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-13 | 2022-05-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-13 | 2022-05-24 | 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 | 2022-04-13 | 2022-05-24 | 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 | 2022-04-13 | 2022-05-24 | N |
| 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 | 2022-04-13 | 2022-05-24 | 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 | 2022-04-13 | 2022-05-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-13 | 2022-05-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-13 | 2022-05-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-13 | 2022-05-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-04-13 | 2022-05-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-13 | 2022-05-24 | 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 | 2022-04-13 | 2022-05-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-13 | 2022-05-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-13 | 2022-05-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-13 | 2022-05-24 | 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 | 2022-04-13 | 2022-05-24 | Y |
| Dispose of garbage and refuse properly. | Health | 2022-04-13 | 2022-05-24 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-02-09 | 2022-03-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-09 | 2022-03-14 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-02-09 | 2022-03-14 | Y |
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