Deficiency Records for Oak Grove Health and Rehab Center, LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Oak Grove Health and Rehab Center, LLC. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-09 | 2023-08-09 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-03 | 2022-03-08 | N |
| Provide appropriate foot care. | Health | 2022-01-28 | 2022-03-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-28 | 2022-03-04 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-01-28 | 2022-03-04 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-01-28 | 2022-03-04 | 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 | 2022-01-28 | 2022-03-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-28 | 2022-03-04 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-28 | 2022-03-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-28 | 2022-03-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-19 | 2019-09-30 | 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 | 2019-07-19 | 2019-09-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-19 | 2019-08-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-07-19 | 2019-08-26 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-07-19 | 2019-08-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-19 | 2019-08-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-19 | 2019-08-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-19 | 2019-08-26 | 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 | 2019-07-19 | 2019-08-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-19 | 2019-08-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-19 | 2019-08-26 | 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 | 2019-07-19 | 2019-08-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-07-19 | 2019-08-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-07-19 | 2019-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-19 | 2019-08-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-19 | 2019-08-26 | N |
| 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 | 2019-07-19 | 2019-07-05 | 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 | 2019-07-19 | 2019-07-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2017-12-11 | 2018-03-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-11 | 2018-02-22 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2017-12-11 | 2018-02-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-12-11 | 2018-02-22 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2017-12-11 | 2018-02-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2017-12-11 | 2018-02-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2017-12-11 | 2018-02-22 | 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 | 2017-12-11 | 2018-02-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2017-12-11 | 2018-02-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-11 | 2018-02-22 | 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 | 2017-12-11 | 2018-02-22 | N |
| Provide activities to meet all resident's needs. | Health | 2017-12-11 | 2018-02-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2017-12-11 | 2018-02-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-11 | 2018-02-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2017-12-11 | 2018-02-22 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2017-12-11 | 2018-02-22 | 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 | 2017-12-11 | 2018-02-22 | N |
| Post nurse staffing information every day. | Health | 2017-12-11 | 2018-02-22 | 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 | 2017-12-11 | 2018-02-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2017-12-11 | 2018-02-22 | N |
| Provide or obtain dental services for each resident. | Health | 2017-12-11 | 2018-02-22 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2017-12-11 | 2018-02-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2017-12-11 | 2018-02-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2017-12-11 | 2018-02-22 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2017-12-11 | 2018-02-22 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2017-12-11 | 2018-02-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2017-12-11 | 2018-02-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2017-12-11 | 2018-02-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2017-12-11 | 2018-02-22 | N |
