Deficiency Records for Oak Glen Post Acute
Updated as of August 01, 2024
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Deficiency Records for Oak Glen Post Acute
A list of the most recent deficiencies for Oak Glen Post Acute. 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 Glen Post Acute. 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? |
|---|---|---|---|---|
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-16 | 2024-06-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-12 | 2024-04-16 | 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 | 2024-04-12 | 2024-04-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-04-12 | 2024-04-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-12 | 2024-04-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-04-12 | 2024-04-16 | N |
| 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 | 2024-04-12 | 2024-04-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-04-12 | 2024-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-12 | 2024-04-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-04-12 | 2024-04-16 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-04-12 | 2024-04-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-20 | 2024-04-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-22 | 2024-02-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-10 | 2022-12-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-10 | 2022-12-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-10 | 2022-12-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-10 | 2022-12-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-10 | 2022-12-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-10 | 2022-12-07 | 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 | 2022-11-10 | 2022-12-07 | 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 | 2022-11-10 | 2022-12-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-10 | 2022-12-07 | N |
| 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 | 2022-11-10 | 2022-12-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-10 | 2022-12-07 | N |
| Dispose of garbage and refuse properly. | Health | 2022-11-10 | 2022-12-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-10 | 2022-12-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-14 | 2022-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-31 | 2022-09-21 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-06-03 | 2022-06-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-03 | 2022-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-24 | 2022-06-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-22 | 2022-04-26 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-03-10 | 2022-04-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-07 | 2022-01-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-09-08 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2019-09-19 | 2019-10-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-19 | 2019-10-07 | 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 | 2019-08-09 | 2019-09-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-08-09 | 2019-09-19 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-08-09 | 2019-09-19 | 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 | 2019-08-09 | 2019-09-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-09 | 2019-09-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-09 | 2019-09-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-09 | 2019-09-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-09 | 2019-09-19 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-08-09 | 2019-09-19 | N |
| 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 | 2019-08-09 | 2019-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-09 | 2019-09-19 | N |
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