A list of the most recent deficiencies for Oakland Manor. 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-31 | 2023-09-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-31 | 2023-09-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-31 | 2023-09-28 | 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 | 2023-08-31 | 2023-09-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-31 | 2023-09-28 | 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 | 2023-08-31 | 2023-09-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-31 | 2023-09-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-31 | 2023-09-28 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-31 | 2023-09-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-31 | 2023-09-28 | 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 | 2023-08-31 | 2023-09-28 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-08-31 | 2023-09-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-31 | 2023-09-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-31 | 2023-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-09-28 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-08-31 | 2023-09-28 | Y |
| Develop a communication plan. | Fire Safety | 2023-09-05 | 2023-09-06 | 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 | 2023-09-05 | 2023-09-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2023-09-05 | 2023-09-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-05 | 2023-09-05 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-11 | 2023-07-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-03 | 2022-06-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-03 | 2022-06-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-03 | 2022-06-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-03 | 2022-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-03 | 2022-06-24 | Y |
| Provide appropriate foot care. | Health | 2022-06-03 | 2022-06-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-03 | 2022-06-24 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-03 | 2022-06-24 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-03 | 2022-06-24 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-06-03 | 2022-06-24 | Y |
| Post nurse staffing information every day. | Health | 2022-06-03 | 2022-06-24 | Y |
| 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 | 2022-06-03 | 2022-06-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-03 | 2022-06-24 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-06-03 | 2022-06-24 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-03 | 2022-06-24 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-03 | 2022-06-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-03 | 2022-06-24 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-06 | 2022-06-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-06 | 2022-06-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-06-06 | 2022-06-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-06 | 2022-06-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-06 | 2022-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-06 | 2022-06-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-06 | 2022-06-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-06 | 2022-06-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-06 | 2022-06-20 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-06-06 | 2022-06-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-06 | 2022-06-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-06-06 | 2022-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-25 | 2022-04-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-20 | 2022-04-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-20 | 2022-04-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-20 | 2022-04-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-20 | 2021-12-29 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-12-20 | 2021-12-29 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-12-20 | 2021-12-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-20 | 2021-12-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-20 | 2021-12-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-20 | 2021-12-29 | Y |
| 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 | 2021-12-20 | 2021-12-29 | 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 | 2021-12-20 | 2021-12-29 | 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 | 2021-12-20 | 2021-12-29 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-20 | 2021-12-29 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-12-20 | 2021-12-29 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-13 | 2020-06-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-13 | 2020-03-13 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-02-06 | 2020-03-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-02-06 | 2020-03-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-06 | 2020-03-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-06 | 2020-03-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-06 | 2020-03-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-06 | 2020-03-11 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-02-06 | 2020-03-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-06 | 2020-03-11 | 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 | 2020-02-06 | 2020-03-11 | 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 | 2020-02-06 | 2020-03-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-06 | 2020-03-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-06 | 2020-03-11 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-13 | 2020-02-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-13 | 2020-02-18 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-13 | 2020-02-14 | 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 | 2020-02-13 | 2020-02-14 | 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 | 2020-02-13 | 2020-02-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-13 | 2020-02-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-13 | 2020-02-13 | N |
