Deficiency Records for Bardmoor Oaks Healthcare and Rehabilitation Cente
Updated as of March 01, 2024
A list of the most recent deficiencies for Bardmoor Oaks Healthcare and Rehabilitation Cente. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-03 | 2022-12-03 | 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 | 2022-11-03 | 2022-12-03 | Y |
| 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 | 2022-11-03 | 2022-12-03 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-11-03 | 2022-12-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-03 | 2022-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-01 | 2022-07-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-01 | 2022-05-01 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-04-01 | 2022-05-01 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-04-01 | 2022-05-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-01 | 2022-05-01 | 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 | 2022-04-01 | 2022-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-01 | 2022-05-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-01 | 2022-05-01 | 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 | 2022-04-01 | 2022-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-01 | 2022-05-01 | N |
| Dispose of garbage and refuse properly. | Health | 2022-04-01 | 2022-05-01 | 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 | 2022-04-01 | 2022-05-01 | Y |
| 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 | 2022-04-01 | 2022-05-01 | Y |
| Post nurse staffing information every day. | Health | 2022-04-01 | 2022-05-01 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-01 | 2022-05-01 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-04-01 | 2022-05-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-18 | 2021-12-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-18 | 2021-12-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-18 | 2021-12-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-18 | 2021-12-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-02 | 2021-04-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-02 | 2021-04-27 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-01-29 | 2021-02-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-01-29 | 2021-02-26 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-01-29 | 2021-02-26 | 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 | 2021-01-29 | 2021-02-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-01-29 | 2021-02-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-01-27 | 2021-02-26 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2021-01-27 | 2021-02-26 | 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 | 2019-08-15 | 2019-09-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-15 | 2019-09-15 | 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 | 2019-08-15 | 2019-09-15 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-08-15 | 2019-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-15 | 2019-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-15 | 2019-09-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-14 | 2019-09-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-14 | 2019-09-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-14 | 2019-09-15 | N |
