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Deficiency Records for Armour Oaks Senior Living Community
A list of the most recent deficiencies for Armour Oaks Senior Living Community. 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 Armour Oaks Senior Living Community. 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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-16 | 2024-03-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-01-16 | 2024-03-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-16 | 2024-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-16 | 2024-03-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-16 | 2024-03-01 | 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 | 2024-01-16 | 2024-03-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-16 | 2024-03-01 | 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 | 2024-01-16 | 2024-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-16 | 2024-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-16 | 2024-03-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-16 | 2024-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-16 | 2024-03-01 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-16 | 2024-03-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-15 | 2023-03-15 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-13 | 2022-11-25 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-13 | 2022-11-25 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-20 | 2022-08-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-20 | 2022-08-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-20 | 2022-08-30 | 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 | 2022-07-20 | 2022-08-30 | 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 | 2022-07-20 | 2022-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-20 | 2022-08-30 | N |
| 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 | 2022-07-20 | 2022-08-30 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-07-20 | 2022-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-20 | 2022-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-20 | 2022-08-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-20 | 2022-08-30 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-07-20 | 2022-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-20 | 2022-08-30 | 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 | 2019-09-18 | 2019-11-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-18 | 2019-11-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-18 | 2019-11-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-18 | 2019-11-02 | 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 | 2019-09-18 | 2019-11-02 | 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 | 2019-09-18 | 2019-11-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-18 | 2019-11-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-18 | 2019-11-02 | 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 | 2019-09-18 | 2019-11-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-18 | 2019-11-02 | N |
| Dispose of garbage and refuse properly. | Health | 2019-09-18 | 2019-11-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-18 | 2019-11-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-18 | 2019-11-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-18 | 2019-11-02 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-09-18 | 2019-11-02 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-09-18 | 2019-11-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-18 | 2019-11-02 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-18 | 2019-11-02 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-09-18 | 2019-11-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-18 | 2019-11-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-18 | 2019-11-02 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-09-18 | 2019-11-02 | N |
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