Deficiency Records for Glenoaks Convalescent Hospital
Updated as of April 01, 2019
This is not the most recent data for Glenoaks Convalescent Hospital. For the most recent information, click here.
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? |
---|---|---|---|---|
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-11-05 | 2018-11-27 | Y |
Provide and implement an infection prevention and control program. | Health | 2018-11-05 | 2018-11-27 | Y |
Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
Establish policies and procedures for sheltering. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
Create arrangements with other facilities to receive patients. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
List the names and contact information of those in the facility. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
Conduct testing and exercise requirements. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
Implement emergency and standby power systems. | Fire Safety | 2018-10-05 | 2018-11-14 | 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 | 2018-10-05 | 2018-11-14 | N |
Construct fire resistant interior walls. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
Meet other general requirements. | Fire Safety | 2018-10-05 | 2018-11-14 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-22 | 2018-10-16 | 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 | 2018-09-22 | 2018-10-16 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-22 | 2018-10-16 | N |
Respond appropriately to all alleged violations. | Health | 2018-09-22 | 2018-10-16 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-22 | 2018-10-16 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-22 | 2018-10-16 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-22 | 2018-10-16 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-22 | 2018-10-16 | 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 | 2018-09-22 | 2018-10-16 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2018-09-22 | 2018-10-16 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-22 | 2018-10-16 | 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 | 2018-09-22 | 2018-10-16 | 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 ne | Health | 2018-09-22 | 2018-10-16 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-22 | 2018-10-16 | 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 | 2018-09-22 | 2018-10-16 | N |
Provide and implement an infection prevention and control program. | Health | 2018-09-22 | 2018-10-16 | N |
Keep all essential equipment working safely. | Health | 2018-09-22 | 2018-10-16 | N |
Keep residents' personal and medical records private and confidential. | Health | 2017-09-23 | 2017-12-21 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-09-23 | 2017-12-21 | N |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-23 | 2017-12-21 | N |
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-09-23 | 2017-12-21 | N |
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2017-09-23 | 2017-12-21 | N |
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-09-23 | 2017-12-21 | N |
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-09-23 | 2017-12-21 | N |
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | Health | 2017-09-23 | 2017-12-21 | N |
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-09-23 | 2017-12-21 | N |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-23 | 2017-12-21 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-10-06 | 2017-11-01 | 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 | 2017-10-06 | 2017-11-01 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-10-06 | 2017-11-01 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-10-06 | 2017-11-01 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-10-06 | 2017-11-01 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-10-06 | 2017-11-01 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2017-10-06 | 2017-11-01 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-10-06 | 2017-11-01 | N |
Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-10-06 | 2017-11-01 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-09-23 | 2017-11-01 | N |
Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-09-23 | 2017-11-01 | N |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-09-23 | 2017-11-01 | N |
Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. | Health | 2017-09-23 | 2017-11-01 | N |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-09-23 | 2017-11-01 | N |
Ensure residents maintain acceptable nutritional status. | Health | 2017-09-23 | 2017-11-01 | N |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-09-23 | 2017-11-01 | N |
Store, cook, and serve food in a safe and clean way. | Health | 2017-09-23 | 2017-11-01 | N |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-23 | 2017-11-01 | N |
Keep all essential equipment working safely. | Health | 2017-09-23 | 2017-11-01 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-09-23 | 2017-11-01 | N |
Put firmly secured handrails on each side of hallways. | Health | 2017-09-23 | 2017-11-01 | N |
Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2017-09-23 | 2017-11-01 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-20 | 2017-07-26 | Y |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-06-26 | 2017-06-28 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-02-22 | 2017-03-01 | Y |
Provide properly protected cooking facilities. | Fire Safety | 2016-12-11 | 2017-01-06 | N |
Construct fire resistant interior walls. | Fire Safety | 2016-12-11 | 2017-01-06 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2016-12-11 | 2017-01-06 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2016-12-11 | 2017-01-06 | 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 | 2016-12-11 | 2017-01-06 | Y |
Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2016-12-11 | 2017-01-06 | N |
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-12-11 | 2017-01-06 | N |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2016-12-11 | 2017-01-06 | N |
Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-12-11 | 2017-01-06 | N |
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-12-11 | 2017-01-06 | N |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-12-11 | 2017-01-06 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-11 | 2017-01-06 | N |
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-12-11 | 2017-01-06 | N |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-12-11 | 2017-01-06 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-12-11 | 2017-01-06 | N |
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-12-22 | 2017-01-02 | Y |
Have simulated fire drills held at unexpected times. | Fire Safety | 2016-12-05 | 2016-12-06 | Y |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2016-12-05 | 2016-12-06 | Y |
Meet other general requirements. | Fire Safety | 2016-12-05 | 2016-12-06 | Y |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-10-18 | 2016-12-01 | Y |