A list of the most recent deficiencies for Oakhill Manor Care Center. 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? |
|---|---|---|---|---|
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-11-15 | 2024-03-18 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-11-15 | 2024-03-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-09 | 2024-02-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-15 | 2024-02-08 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-02-16 | 2023-04-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-02-16 | 2023-04-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-16 | 2023-04-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-16 | 2023-04-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-04-01 | 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 | 2023-02-16 | 2023-04-01 | 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 | 2023-02-16 | 2023-04-01 | N |
| 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 | 2023-02-16 | 2023-04-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-16 | 2023-04-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-16 | 2023-04-01 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-02-16 | 2023-04-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-16 | 2023-04-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-14 | 2023-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-14 | 2023-04-01 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-14 | 2023-04-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-14 | 2023-04-01 | N |
| 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 | 2022-12-16 | 2023-01-02 | 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 | 2022-10-24 | 2022-11-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-26 | 2022-11-10 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-09-26 | 2022-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-26 | 2022-11-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-26 | 2022-11-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-26 | 2022-11-10 | Y |
| 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 | 2022-09-26 | 2022-11-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-09-26 | 2022-11-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-26 | 2022-11-10 | 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 | 2022-02-08 | 2022-02-19 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-02-08 | 2022-02-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-10 | 2021-12-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-15 | 2021-11-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-15 | 2021-11-19 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-09-08 | 2021-09-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-27 | 2021-09-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-04-27 | 2021-09-08 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-04-27 | 2021-09-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-04-27 | 2021-09-08 | 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 | 2021-04-27 | 2021-09-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-27 | 2021-09-08 | N |
| Provide activities to meet all resident's needs. | Health | 2021-04-27 | 2021-09-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-27 | 2021-09-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-27 | 2021-09-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-27 | 2021-09-08 | 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 | 2021-04-27 | 2021-09-08 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-04-27 | 2021-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-27 | 2021-09-08 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-04-27 | 2021-09-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-09-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-05 | 2021-09-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-08-05 | 2021-09-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-30 | 2021-09-08 | 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 | 2021-06-30 | 2021-09-08 | 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 | 2021-04-28 | 2021-09-02 | 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 | 2021-04-28 | 2021-09-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-28 | 2021-09-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-28 | 2021-09-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-28 | 2021-09-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-28 | 2021-09-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-28 | 2021-09-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-28 | 2021-09-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-28 | 2021-09-02 | 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 | 2019-01-10 | 2019-01-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-10 | 2019-01-21 | N |
| Provide or obtain dental services for each resident. | Health | 2019-01-10 | 2019-01-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-10 | 2019-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-10 | 2019-01-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-10 | 2019-01-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-01-10 | 2019-01-21 | N |
