A list of the most recent deficiencies for Lady of The Oaks Retirement 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 and implement an infection prevention and control program. | Health | 2023-09-26 | 2023-10-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-26 | 2023-08-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-26 | 2023-08-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-13 | 2023-07-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-29 | 2023-04-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-03-29 | 2023-04-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-29 | 2023-04-21 | 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 | 2023-03-29 | 2023-04-21 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-03-29 | 2023-04-21 | N |
| Keep all essential equipment working safely. | Health | 2023-03-29 | 2023-04-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-21 | 2022-12-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-03 | 2022-09-12 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-03 | 2022-09-12 | 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 | 2022-02-01 | 2022-02-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-01 | 2022-02-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-02-01 | 2022-02-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-01 | 2022-02-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-01 | 2022-02-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-01 | 2022-02-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-13 | 2020-03-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-13 | 2020-03-10 | 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 | 2020-02-13 | 2020-03-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-13 | 2020-03-10 | N |
