A list of the most recent deficiencies for Glenoaks Senior Living Campus. 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? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-23 | 2023-10-19 | N |
| 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 | 2023-09-21 | 2023-10-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-21 | 2023-10-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-21 | 2023-10-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-21 | 2023-10-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-10-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-21 | 2023-10-12 | 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 | 2023-09-21 | 2023-10-12 | 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 | 2023-09-21 | 2023-10-12 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-09-21 | 2023-10-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-21 | 2023-10-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-21 | 2023-10-12 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-21 | 2023-10-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-21 | 2023-10-12 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-08-23 | 2023-09-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-23 | 2023-09-26 | 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 | 2023-08-23 | 2023-09-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-08-23 | 2023-09-26 | 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 | 2023-08-23 | 2023-09-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-23 | 2023-09-26 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-08-23 | 2023-09-26 | 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 | 2023-08-23 | 2023-09-26 | 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 | 2023-08-23 | 2023-09-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-23 | 2023-09-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-23 | 2023-09-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-23 | 2023-09-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-23 | 2023-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-23 | 2023-09-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-23 | 2023-09-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-23 | 2023-09-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-24 | 2023-05-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-24 | 2023-05-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-23 | 2023-04-21 | 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 | 2023-03-23 | 2023-04-19 | Y |
| Keep all essential equipment working safely. | Health | 2023-03-23 | 2023-04-13 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-03-09 | 2023-03-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-09 | 2023-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-30 | 2023-03-10 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-30 | 2023-02-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-30 | 2023-02-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-12 | 2022-12-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-12 | 2022-12-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-29 | 2022-12-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-17 | 2022-12-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-17 | 2022-12-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-17 | 2022-12-22 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-02 | 2022-09-27 | 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 | 2022-08-04 | 2022-09-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-04 | 2022-09-23 | 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 | 2022-08-04 | 2022-09-23 | 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 | 2022-08-04 | 2022-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-04 | 2022-08-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-04 | 2022-08-31 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-08-04 | 2022-08-26 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-02 | 2022-08-26 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-25 | 2022-06-09 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-10-17 | 2019-11-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-17 | 2019-11-25 | N |
