A list of the most recent deficiencies for Glenoaks Convalescent Hospital. 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? |
|---|---|---|---|---|
| Establish staff and initial training requirements. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-11 | 2024-01-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-08 | 2024-01-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-08 | 2024-01-01 | N |
| Provide activities to meet all resident's needs. | Health | 2023-12-08 | 2024-01-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-08 | 2024-01-01 | 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 | 2023-12-08 | 2024-01-01 | 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 | 2023-12-08 | 2024-01-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-12-08 | 2024-01-01 | 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 | 2023-12-08 | 2024-01-01 | 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 | 2023-12-08 | 2024-01-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-08 | 2024-01-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-08 | 2024-01-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-08 | 2024-01-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-08 | 2024-01-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-08 | 2024-01-01 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-09-13 | 2023-11-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-13 | 2023-10-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-13 | 2023-10-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-25 | 2023-09-21 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-08-25 | 2023-09-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-25 | 2023-09-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-25 | 2023-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-25 | 2023-09-21 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-08 | 2023-02-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-12-08 | 2023-02-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-12-08 | 2023-02-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-08 | 2023-02-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-08 | 2023-02-01 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-12-08 | 2023-02-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-08 | 2023-02-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-08 | 2023-02-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-12 | 2023-01-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-12 | 2023-01-20 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-12-12 | 2023-01-20 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2022-12-12 | 2023-01-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-12-12 | 2023-01-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-12 | 2023-01-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-12 | 2023-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-12 | 2023-01-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-12 | 2023-01-20 | N |
| Provide activities to meet all resident's needs. | Health | 2022-12-12 | 2023-01-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-12 | 2023-01-20 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-12-12 | 2023-01-20 | 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 | 2022-12-12 | 2023-01-20 | 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 | 2022-12-12 | 2023-01-20 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-12-12 | 2023-01-20 | N |
| 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 | 2022-12-12 | 2023-01-20 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-12-12 | 2023-01-20 | 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 | 2022-12-12 | 2023-01-20 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-12-12 | 2023-01-20 | 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 | 2022-12-12 | 2023-01-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-12 | 2023-01-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-12 | 2023-01-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-12 | 2023-01-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-12-12 | 2023-01-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-12 | 2023-01-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-12 | 2023-01-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-01 | 2022-11-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-28 | 2022-07-27 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-08-09 | 2022-03-14 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-09-30 | 2021-10-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-08 | 2021-06-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-18 | 2021-05-03 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-04-01 | 2021-04-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-22 | 2019-10-16 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-09-22 | 2019-10-16 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-09-22 | 2019-10-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-22 | 2019-10-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-22 | 2019-10-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-22 | 2019-10-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-22 | 2019-10-16 | 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 | 2019-09-22 | 2019-10-16 | 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 | 2019-09-22 | 2019-10-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-09-22 | 2019-10-16 | N |
| 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 | 2019-09-22 | 2019-10-16 | 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 | 2019-09-22 | 2019-10-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-22 | 2019-10-16 | 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 | 2019-09-22 | 2019-10-16 | 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 | 2019-09-22 | 2019-10-16 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-09-22 | 2019-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-22 | 2019-10-16 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-09-22 | 2019-10-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-22 | 2019-10-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-09-22 | 2019-10-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-22 | 2019-10-16 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-09-22 | 2019-10-16 | 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 | 2019-09-22 | 2019-10-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-22 | 2019-10-16 | N |
