Deficiency Records for Glenoaks Convalescent Hospital
Updated as of March 01, 2022
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? |
|---|---|---|---|---|
| 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 |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2020-11-04 | 2020-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-07-13 | 2020-10-14 | 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 | 2020-07-09 | 2020-08-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-14 | 2020-07-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-06-16 | 2020-06-22 | 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 other general requirements that are deficient. | 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 |
| 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 necessary and PRN use is limited. | 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 |
| 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 |
| 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 |
