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Deficiency Records for Royal Oaks Manor-Bradbury Oaks
A list of the most recent deficiencies for Royal Oaks Manor-Bradbury Oaks. 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 Royal Oaks Manor-Bradbury Oaks. 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 a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-10 | 2024-05-29 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-04-15 | 2024-05-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-28 | 2023-12-11 | Y |
| Construct fire resistant interior walls. | Fire Safety | 2023-11-08 | 2023-12-02 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-11-08 | 2023-12-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-08 | 2023-12-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2023-11-22 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-02 | 2023-11-20 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-11-02 | 2023-11-20 | 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 | 2023-11-02 | 2023-11-20 | 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 | 2023-11-02 | 2023-11-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-02 | 2023-11-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-02 | 2023-11-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-02 | 2023-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-02 | 2023-11-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-02 | 2023-11-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-11-02 | 2023-11-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-02 | 2023-11-10 | 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 | 2023-11-02 | 2023-11-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-02 | 2023-11-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-11-02 | 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 | 2022-11-04 | 2022-12-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-04 | 2022-12-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-04 | 2022-12-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-04 | 2022-12-01 | 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 | 2022-11-04 | 2022-12-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-04 | 2022-12-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-04 | 2022-12-01 | 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 | 2022-11-04 | 2022-12-01 | 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 | 2022-11-04 | 2022-12-01 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-11-09 | 2022-11-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-09 | 2022-11-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-09 | 2022-11-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-04 | 2022-10-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-07 | 2022-04-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-01 | 2022-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-01 | 2022-04-15 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-04-01 | 2022-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-15 | 2022-04-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-10 | 2019-11-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-10-10 | 2019-11-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-10 | 2019-11-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-10 | 2019-11-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-10 | 2019-11-18 | 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 | 2019-10-10 | 2019-11-18 | 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 | 2019-10-10 | 2019-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-10 | 2019-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-10 | 2019-11-18 | N |
| Meet other general requirements. | Fire Safety | 2019-10-11 | 2019-11-15 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-10-11 | 2019-11-15 | 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 | 2019-10-11 | 2019-11-15 | N |
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