Deficiency Records for English Oaks Convalescent and Rehabilitation Hospita
Updated as of March 01, 2024
A list of the most recent deficiencies for English Oaks Convalescent and Rehabilitation Hospita. 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 appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-21 | 2024-01-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-21 | 2024-01-04 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-13 | 2023-11-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-13 | 2023-11-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-06-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-17 | 2023-03-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-17 | 2023-03-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-17 | 2023-03-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-17 | 2023-03-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-17 | 2023-03-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-17 | 2023-03-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-17 | 2023-03-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-17 | 2023-03-21 | 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 | 2023-02-17 | 2023-03-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-17 | 2023-03-21 | 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 | 2023-02-17 | 2023-03-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-23 | 2023-03-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-02 | 2023-02-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-15 | 2021-04-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-15 | 2019-11-21 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-15 | 2019-11-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-08-15 | 2019-11-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-15 | 2019-11-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-15 | 2019-11-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-15 | 2019-11-21 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-15 | 2019-11-21 | 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 | 2019-08-15 | 2019-11-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-08-15 | 2019-11-21 | 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 | 2019-08-15 | 2019-11-21 | 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 | 2019-08-15 | 2019-11-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-15 | 2019-11-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-15 | 2019-11-21 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-08-15 | 2019-11-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-31 | 2018-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-31 | 2018-11-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-09 | 2018-08-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-09 | 2018-08-24 | 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 | 2018-08-09 | 2018-08-24 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-08-09 | 2018-08-24 | N |
