A list of the most recent deficiencies for Oak Park Place of Nakoma. 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 basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-07-20 | 2023-08-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-20 | 2023-08-20 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-07-20 | 2023-08-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-07-20 | 2023-08-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-20 | 2023-08-20 | 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 | 2023-07-20 | 2023-08-20 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-20 | 2023-08-20 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-20 | 2023-08-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-20 | 2023-08-20 | 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 | 2023-07-20 | 2023-08-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-20 | 2023-08-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-20 | 2023-08-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-20 | 2023-08-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-07-20 | 2023-08-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-20 | 2023-08-20 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-07-20 | 2023-08-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-20 | 2023-08-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-20 | 2023-08-20 | 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 | 2022-05-12 | 2022-09-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-12 | 2022-06-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-12 | 2022-06-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-12 | 2022-06-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-05-12 | 2022-06-03 | 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 | 2022-05-11 | 2022-06-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-12 | 2022-06-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-12 | 2022-05-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-12 | 2022-05-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-12 | 2022-05-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-28 | 2021-08-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-08 | 2021-07-07 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-09 | 2021-07-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-09 | 2021-07-07 | 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 | 2021-06-09 | 2021-07-07 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-06-09 | 2021-07-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-09 | 2021-07-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-09 | 2021-07-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-06-09 | 2021-07-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-09 | 2021-07-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-06-09 | 2021-07-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-09 | 2021-07-07 | N |
| 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 | 2021-06-08 | 2021-07-02 | 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 | 2021-06-08 | 2021-07-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-06-08 | 2021-07-02 | N |
