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Deficiency Records for Delta Oaks Post Acute
View the most recent health deficiencies and inspection results for Delta Oaks Post Acute. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Delta Oaks Post Acute. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2026-04-02 | 2026-04-24 | Y |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2026-04-21 | 2026-04-24 | 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 | 2026-04-21 | 2026-04-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-04-02 | 2026-04-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2026-04-02 | 2026-04-24 | Y |
| Assess the resident when there is a significant change in condition | Health | 2026-04-02 | 2026-04-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-03-05 | 2026-03-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2026-02-17 | 2026-02-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2026-02-17 | 2026-02-18 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2025-12-30 | 2026-02-10 | Y |
| Dispose of garbage and refuse properly. | Health | 2025-12-04 | 2025-12-08 | Y |
| Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Health | 2025-11-24 | 2025-12-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-10-02 | 2025-10-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-10-02 | 2025-10-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2025-10-02 | 2025-10-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-10-02 | 2025-10-27 | 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 | 2025-10-02 | 2025-10-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-10-02 | 2025-10-27 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2025-10-02 | 2025-10-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-10-02 | 2025-10-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-10-02 | 2025-10-27 | 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 | 2025-10-02 | 2025-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-10-02 | 2025-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-10-02 | 2025-10-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-10-02 | 2025-10-27 | 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 | 2025-10-02 | 2025-10-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2025-10-02 | 2025-10-27 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2025-09-25 | 2025-10-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-09-25 | 2025-10-03 | Y |
| 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 | 2025-09-25 | 2025-10-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-08-22 | 2025-08-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-08-08 | 2025-08-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-18 | 2025-06-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-06-25 | 2025-06-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-05-27 | 2025-06-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-06-05 | 2025-06-06 | Y |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-05-15 | 2025-05-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-04-08 | 2025-04-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-02-06 | 2025-02-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-10-22 | 2024-11-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-10-22 | 2024-11-15 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-10-22 | 2024-11-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-10-22 | 2024-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-11-05 | 2024-10-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-11-05 | 2024-10-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-11-05 | 2024-10-30 | 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 | 2024-10-18 | 2024-10-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-10-18 | 2024-10-07 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-01 | 2024-10-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-01 | 2024-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-01 | 2024-10-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-08-01 | 2024-10-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-08-01 | 2024-10-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-01 | 2024-10-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-08-01 | 2024-10-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-08-01 | 2024-10-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-01 | 2024-10-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-08-01 | 2024-10-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-04 | 2024-09-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-22 | 2024-08-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-01 | 2024-08-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-01 | 2024-08-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-01 | 2024-08-12 | 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 | 2024-08-01 | 2024-08-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-08-01 | 2024-08-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-01 | 2024-08-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-01 | 2024-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-01 | 2024-08-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-01 | 2024-08-12 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-08-01 | 2024-08-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-01 | 2024-08-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-01 | 2024-08-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-01 | 2024-08-12 | 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 | 2024-08-01 | 2024-08-12 | N |
| Provide or obtain dental services for each resident. | Health | 2024-08-01 | 2024-08-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-01 | 2024-08-12 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-08-01 | 2024-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-01 | 2024-08-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-01 | 2024-08-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-08-01 | 2024-08-12 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-07-16 | 2024-08-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-17 | 2024-08-07 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-07-17 | 2024-08-07 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-07-17 | 2024-08-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-17 | 2024-08-07 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-18 | 2024-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-11 | 2024-06-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-06-11 | 2024-06-28 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-05-30 | 2024-06-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-30 | 2024-06-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-10 | 2024-06-17 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-28 | 2024-06-02 | Y |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2024-05-28 | 2024-06-02 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-04-15 | 2024-04-26 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-04-15 | 2024-04-26 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-04-15 | 2024-04-26 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-03-18 | 2024-04-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-15 | 2024-04-04 | 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 | 2024-03-15 | 2024-04-04 | 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 | 2024-01-03 | 2024-01-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-28 | 2024-01-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-08 | 2023-11-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-24 | 2023-10-26 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-26 | 2023-10-17 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Use approved construction type or materials. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-20 | 2023-09-19 | 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 | 2023-07-20 | 2023-09-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-20 | 2023-09-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-20 | 2023-08-01 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-07-20 | 2023-08-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-07-20 | 2023-08-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-20 | 2023-08-01 | 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 | 2023-07-20 | 2023-08-01 | 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 | 2023-07-20 | 2023-08-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-20 | 2023-08-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-20 | 2023-08-01 | 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 | 2023-07-20 | 2023-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-20 | 2023-08-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-20 | 2023-08-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-07-20 | 2023-08-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-20 | 2023-08-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-20 | 2023-08-01 | 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 | 2023-07-20 | 2023-08-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-20 | 2023-08-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-07-20 | 2023-08-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-06-20 | 2019-08-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-20 | 2019-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-20 | 2019-08-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-20 | 2019-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-04-15 | Not Fixed | Y |
| Ensure that residents are free from significant medication errors. | Health | 2026-04-15 | Not Fixed | 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 | 2026-04-15 | Not Fixed | Y |
| Provide and implement an infection prevention and control program. | Health | 2026-04-15 | Not Fixed | Y |