A list of the most recent deficiencies for Diversicare of Oak Ridge. 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 approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-15 | 2023-12-21 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-03 | 2023-11-22 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-27 | 2023-11-22 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-09-22 | 2023-10-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-22 | 2023-10-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-22 | 2023-10-19 | 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 | 2023-09-22 | 2023-10-19 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-22 | 2023-10-19 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-06 | 2023-10-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-06 | 2023-10-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-09-06 | 2023-10-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-06 | 2023-10-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-09-22 | 2023-10-18 | N |
| Provide appropriate foot care. | Health | 2023-09-22 | 2023-10-18 | 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 | 2023-09-22 | 2023-10-18 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-09-22 | 2023-10-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-22 | 2023-10-13 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-22 | 2023-10-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-22 | 2023-10-12 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-09-22 | 2023-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-22 | 2023-09-28 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-09-22 | 2023-09-27 | Y |
| 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 | 2023-09-22 | 2023-09-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-10-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-26 | 2022-03-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-01-26 | 2022-03-31 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-01-26 | 2022-03-31 | N |
| Post nurse staffing information every day. | Health | 2022-01-26 | 2022-03-31 | 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 | 2022-01-26 | 2022-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-26 | 2022-03-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-26 | 2022-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-26 | 2022-03-31 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-26 | 2022-03-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-01-23 | 2022-03-09 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-12 | 2021-11-05 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-12 | 2021-09-20 | Y |
| Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials. | Health | 2021-08-12 | 2021-09-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-12 | 2021-09-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-12 | 2021-09-20 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-08-12 | 2021-09-20 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-08-12 | 2021-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-12 | 2021-09-20 | Y |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-04-08 | 2019-06-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-10 | 2019-05-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-10 | 2019-05-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-10 | 2019-05-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-08 | 2019-05-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-08 | 2019-04-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-10 | Not Fixed | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-10 | Not Fixed | 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 | 2023-05-10 | Not Fixed | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-10 | Not Fixed | Y |
