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Deficiency Records for Midtown Oaks Health and Rehab Center
A list of the most recent deficiencies for Midtown Oaks Health and Rehab 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 Midtown Oaks Health and Rehab 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? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-08-22 | 2024-10-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-22 | 2024-10-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-22 | 2024-10-01 | 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 | 2024-08-22 | 2024-10-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-08-22 | 2024-10-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-22 | 2024-10-01 | 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 | 2024-08-22 | 2024-10-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-22 | 2024-10-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-08-22 | 2024-10-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-08-22 | 2024-10-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-22 | 2024-10-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-22 | 2024-10-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-08-22 | 2024-10-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-22 | 2024-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-22 | 2024-10-01 | 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 | 2024-08-22 | 2024-10-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-22 | 2024-10-01 | 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 | 2024-08-22 | 2024-10-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-22 | 2024-10-01 | 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 | 2024-08-22 | 2024-10-01 | 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 | 2024-08-22 | 2024-10-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-22 | 2024-10-01 | 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 | 2024-08-22 | 2024-10-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-22 | 2024-10-01 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-08-22 | 2024-10-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-22 | 2024-10-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-08-22 | 2024-10-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-08-22 | 2024-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-22 | 2024-10-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-08-22 | 2024-10-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-08-22 | 2024-10-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-08-22 | 2024-10-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-08-21 | 2024-09-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-08-21 | 2024-09-16 | N |
| Meet other general requirements. | Fire Safety | 2024-08-21 | 2024-09-16 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-08-21 | 2024-09-16 | 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 | 2024-08-21 | 2024-09-16 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2024-08-21 | 2024-09-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-08-21 | 2024-09-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-21 | 2024-09-16 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2024-08-21 | 2024-09-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-08-21 | 2024-09-16 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-08-21 | 2024-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-21 | 2024-09-16 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-07-03 | 2024-08-01 | 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 | 2024-07-03 | 2024-08-01 | 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 | 2024-07-03 | 2024-08-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-03 | 2024-08-01 | 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 | 2024-07-03 | 2024-08-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-03 | 2024-08-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-03 | 2024-08-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-03 | 2024-08-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-03 | 2024-08-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-03 | 2024-08-01 | 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 | 2024-07-03 | 2024-08-01 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-07-03 | 2024-08-01 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-07-03 | 2024-08-01 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-07-03 | 2024-08-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-03 | 2024-08-01 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-07-03 | 2024-08-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-18 | 2024-08-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-18 | 2024-05-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-18 | 2024-05-16 | 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 | 2024-04-18 | 2024-05-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-18 | 2024-05-16 | 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 | 2024-04-18 | 2024-05-16 | Y |
| Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable. | Health | 2024-04-18 | 2024-05-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-20 | 2024-04-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-05 | 2024-02-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-05 | 2024-02-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-05 | 2024-02-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-05 | 2024-02-02 | Y |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2024-01-05 | 2024-02-02 | 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 | 2023-11-15 | 2023-12-13 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-11-15 | 2023-12-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-15 | 2023-12-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-15 | 2023-12-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2023-12-13 | 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 | 2023-11-15 | 2023-12-13 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-15 | 2023-12-13 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-15 | 2023-12-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-08 | 2023-10-06 | 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 | 2023-09-08 | 2023-10-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-08 | 2023-10-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-08 | 2023-10-06 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-09-08 | 2023-10-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-08 | 2023-10-06 | 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 | 2023-09-08 | 2023-10-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-08 | 2023-10-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-08 | 2023-10-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-08 | 2023-10-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-08 | 2023-10-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-08 | 2023-10-06 | 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 | 2023-09-08 | 2023-10-06 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-09-08 | 2023-10-06 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-09-08 | 2023-10-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-08 | 2023-10-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-08 | 2023-10-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-08 | 2023-10-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-08 | 2023-10-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-08 | 2023-10-06 | 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 | 2023-09-08 | 2023-10-06 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-08 | 2023-10-06 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-12 | 2023-09-25 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-09-12 | 2023-09-25 | 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 | 2023-09-12 | 2023-09-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-12 | 2023-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-12 | 2023-09-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-12 | 2023-09-25 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-09-12 | 2023-09-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-12 | 2023-09-25 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-09-12 | 2023-09-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-30 | 2023-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-30 | 2023-06-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-30 | 2023-06-22 | 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 | 2023-03-07 | 2023-04-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-07 | 2023-04-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-23 | 2023-04-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-23 | 2023-04-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-23 | 2023-04-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-23 | 2023-04-23 | 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 | 2023-02-23 | 2023-04-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-28 | 2023-02-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-28 | 2023-02-08 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-11-03 | 2022-12-19 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-11-03 | 2022-12-19 | 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 | 2022-11-03 | 2022-12-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-03 | 2022-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-03 | 2022-12-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-03 | 2022-12-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-03 | 2022-12-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-03 | 2022-12-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-11-03 | 2022-12-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-03 | 2022-12-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-03 | 2022-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-03 | 2022-12-19 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-10-27 | 2022-12-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-10-27 | 2022-12-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-10-27 | 2022-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-27 | 2022-12-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-27 | 2022-12-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-27 | 2022-12-14 | 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 | 2022-10-27 | 2022-12-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-27 | 2022-12-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-27 | 2022-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-27 | 2022-12-14 | N |
| Report COVID19 data to residents and families. | Health | 2022-10-27 | 2022-12-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-10 | 2021-12-17 | Y |
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