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Deficiency Records for Oak Grove Manor
A list of the most recent deficiencies for Oak Grove 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 Oak Grove 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2024-07-31 | 2024-08-22 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-07-31 | 2024-08-22 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-07-31 | 2024-08-22 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-07-31 | 2024-08-22 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-05-16 | 2024-06-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-16 | 2024-06-07 | N |
| Dispose of garbage and refuse properly. | Health | 2024-05-16 | 2024-06-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-16 | 2024-06-07 | Y |
| 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 | 2024-05-16 | 2024-06-07 | 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 | 2024-05-16 | 2024-06-07 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-05-16 | 2024-06-07 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2024-05-16 | 2024-06-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-16 | 2024-06-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-16 | 2024-06-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-16 | 2024-06-07 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-15 | 2024-06-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-06 | 2024-02-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-06 | 2024-02-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-06 | 2024-02-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-06 | 2024-02-24 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-02-06 | 2024-02-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-06 | 2024-02-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-06 | 2024-02-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-27 | 2024-02-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-21 | 2023-12-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-21 | 2023-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-26 | 2023-10-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-01 | 2023-09-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-01 | 2023-09-01 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-31 | 2023-09-01 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-31 | 2023-09-01 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-11-15 | 2023-03-14 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-11-15 | 2023-03-14 | 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 | 2023-02-24 | 2023-03-07 | 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 | 2023-02-24 | 2023-03-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-24 | 2023-03-07 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-07 | 2023-03-07 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-10 | 2023-03-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-10 | 2023-03-07 | 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 | 2023-01-10 | 2023-03-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-05 | 2023-03-07 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-15 | 2023-03-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-15 | 2023-03-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-15 | 2023-03-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-15 | 2023-03-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-15 | 2023-03-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-15 | 2023-03-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-15 | 2023-03-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-15 | 2023-03-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-15 | 2023-03-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-15 | 2023-03-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-15 | 2023-03-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-09 | 2023-03-06 | 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 | 2022-04-27 | 2022-05-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-27 | 2022-05-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-27 | 2022-05-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-27 | 2022-05-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-27 | 2022-05-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-25 | 2022-04-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-25 | 2022-04-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-25 | 2022-04-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-17 | 2021-12-03 | 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 | 2019-10-17 | 2019-11-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-17 | 2019-11-20 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-16 | 2019-11-20 | 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 | 2019-10-16 | 2019-11-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
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