A list of the most recent deficiencies for Oak Grove 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-27 | 2024-01-10 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-21 | 2023-12-01 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-21 | 2023-12-01 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-09-26 | 2023-10-06 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-01 | 2023-09-01 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-01 | 2023-09-01 | Y |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-31 | 2023-09-01 | Y |
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-31 | 2023-09-01 | Y |
Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-11-15 | 2023-03-14 | N |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-11-15 | 2023-03-14 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | N |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-15 | 2023-03-07 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-15 | 2023-03-07 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-15 | 2023-03-07 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-15 | 2023-03-07 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-15 | 2023-03-07 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-15 | 2023-03-07 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-15 | 2023-03-07 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-15 | 2023-03-07 | N |
Ensure that residents are free from significant medication errors. | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-15 | 2023-03-07 | N |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-15 | 2023-03-07 | N |
Provide and implement an infection prevention and control program. | Health | 2022-11-15 | 2023-03-07 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-15 | 2023-03-07 | 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 | 2022-11-15 | 2023-03-07 | Y |
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 | 2023-02-24 | 2023-03-07 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-24 | 2023-03-07 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-24 | 2023-03-07 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-07 | 2023-03-07 | Y |
Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-10 | 2023-03-07 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-10 | 2023-03-07 | 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 | 2023-01-10 | 2023-03-07 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-05 | 2023-03-07 | Y |
Provide properly protected cooking facilities. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-09 | 2023-03-06 | N |
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 | 2022-04-27 | 2022-05-20 | Y |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-27 | 2022-05-20 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-27 | 2022-05-20 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-04-27 | 2022-05-20 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-27 | 2022-05-20 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-25 | 2022-04-01 | Y |
Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-25 | 2022-04-01 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-25 | 2022-04-01 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-17 | 2021-12-03 | 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 | 2019-10-17 | 2019-11-20 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-17 | 2019-11-20 | N |
Use approved construction type or materials. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-16 | 2019-11-20 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2018-08-23 | 2018-09-24 | 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 | 2018-08-23 | 2018-09-24 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-23 | 2018-09-24 | N |
Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-08-23 | 2018-09-24 | N |
Ensure each resident receives an accurate assessment. | Health | 2018-08-23 | 2018-09-24 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-08-23 | 2018-09-24 | N |
Honor each resident's preferences, choices, values and beliefs. | Health | 2018-08-23 | 2018-09-24 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-23 | 2018-09-24 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-23 | 2018-09-24 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-08-23 | 2018-09-24 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-23 | 2018-09-24 | N |
Provide and implement an infection prevention and control program. | Health | 2018-08-23 | 2018-09-24 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-21 | 2018-09-24 | N |