A list of the most recent deficiencies for Mid-Town Oaks 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? |
|---|---|---|---|---|
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-12 | 2024-02-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-01-08 | 2024-01-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-13 | 2023-12-22 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-14 | 2023-10-12 | 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 | 2023-09-14 | 2023-10-12 | 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 | 2023-09-14 | 2023-10-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-09-14 | 2023-10-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-14 | 2023-10-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-14 | 2023-10-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-14 | 2023-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-14 | 2023-10-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-14 | 2023-10-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-14 | 2023-10-12 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-09-14 | 2023-10-12 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-14 | 2023-10-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-14 | 2023-10-12 | 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 | 2023-09-14 | 2023-10-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-14 | 2023-10-12 | 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 | 2023-09-14 | 2023-10-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-14 | 2023-10-12 | N |
| Dispose of garbage and refuse properly. | Health | 2023-09-14 | 2023-10-12 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-09-14 | 2023-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-14 | 2023-10-12 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-14 | 2023-10-12 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-08-16 | 2023-09-27 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-19 | 2023-09-20 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-08-17 | 2023-09-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-29 | 2023-07-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-29 | 2023-07-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-29 | 2023-07-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-06 | 2023-07-21 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-19 | 2023-07-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-15 | 2023-06-30 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-06-15 | 2023-06-30 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-21 | 2023-03-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-26 | 2022-11-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-11 | 2022-10-28 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2022-10-11 | 2022-10-28 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-20 | 2022-10-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-07 | 2022-09-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-18 | 2022-07-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-31 | 2022-06-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-31 | 2022-06-10 | Y |
| 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 | 2021-08-24 | 2021-09-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-06-10 | 2021-07-09 | 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 | 2021-06-10 | 2021-07-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-10 | 2021-07-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-10 | 2021-07-09 | 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 | 2021-06-10 | 2021-07-09 | 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 | 2021-06-10 | 2021-07-09 | 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 | 2021-06-10 | 2021-07-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-06-10 | 2021-07-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-10 | 2021-07-09 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-06-10 | 2021-07-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-10 | 2021-07-09 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-06-23 | 2021-07-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-23 | 2021-07-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-23 | 2021-07-09 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-06-04 | 2021-06-26 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-04 | 2021-06-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-04 | 2021-06-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-08 | 2019-10-15 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-08-08 | 2019-10-15 | 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 | 2019-08-08 | 2019-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-08 | 2019-10-15 | 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 | 2019-08-08 | 2019-10-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-08 | 2019-10-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-08 | 2019-10-15 | 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 | 2019-08-08 | 2019-10-15 | 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 | 2019-08-08 | 2019-10-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-08 | 2019-10-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-08 | 2019-10-15 | 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 | 2019-08-08 | 2019-10-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-08 | 2019-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-08 | 2019-10-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-09-03 | 2019-09-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-03 | 2019-09-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-03 | 2019-09-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-03 | 2019-09-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-03 | 2019-09-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-03 | 2019-09-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-03 | 2019-09-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-03 | 2019-09-16 | N |
