A list of the most recent deficiencies for The Oaks at Sweeten Creek. 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? |
|---|---|---|---|---|
| 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 | 2024-01-16 | 2024-02-14 | 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 | 2024-01-16 | 2024-02-14 | 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 | 2024-01-16 | 2024-02-14 | N |
| 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 | 2024-01-16 | 2024-02-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-16 | 2024-02-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-16 | 2024-02-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-16 | 2024-02-14 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-01-16 | 2024-02-14 | Y |
| 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 | 2024-01-16 | 2024-02-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-16 | 2024-02-14 | Y |
| Provide or obtain dental services for each resident. | Health | 2024-01-16 | 2024-02-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-01-16 | 2024-02-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-16 | 2024-02-14 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-01-16 | 2024-02-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-28 | 2024-01-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-28 | 2024-01-16 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-05-03 | 2023-05-30 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-05-03 | 2023-05-30 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-03 | 2023-05-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-03 | 2023-05-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-04-10 | Y |
| 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 | 2022-07-19 | 2022-08-30 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-07-19 | 2022-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-19 | 2022-08-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-19 | 2022-08-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-24 | 2022-07-25 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-24 | 2022-07-25 | 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 | 2022-06-24 | 2022-07-25 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-24 | 2022-07-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-24 | 2022-07-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-24 | 2022-07-25 | Y |
| 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 | 2022-06-24 | 2022-07-25 | 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 | 2022-06-24 | 2022-07-25 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-06-24 | 2022-07-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-24 | 2022-07-25 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-27 | 2020-06-27 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-02-27 | 2020-06-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-27 | 2020-06-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-27 | 2020-06-27 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2020-02-27 | 2020-06-27 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-01-16 | 2020-02-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-01-16 | 2020-02-12 | 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 | 2020-01-16 | 2020-02-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-16 | 2020-02-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-16 | 2020-02-12 | N |
| Dispose of garbage and refuse properly. | Health | 2020-01-16 | 2020-02-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-16 | 2020-02-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-16 | 2019-03-02 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-01-16 | 2019-03-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-01-16 | 2019-03-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-16 | 2019-03-02 | N |
