Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00217329 Renewal 01/10/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Individual #1's individual rights, reviewed on 8/4/2022, did not include 6400.32(s) the right to have the key or entry device to lock and unlock the door.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Rights document was corrected and the corrected rights will be explained to each individual and documentation will be entered in to the individuals file. 01/19/2023 Implemented
SIN-00199905 Renewal 02/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1's February 2022 medication administration record did not include the diagnosis or purpose for the following medications: Atenolol 25mg tablet, Clonidine HCL .3mg tablet, Lisinopril 2.5mg tablet, Multi-vitamin 50 & over QC, Rosuvastatin 20mg tablet, and Vitamin D3 5,000 unit tablet.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.On 2/11/2022, the RP Supervisor contacted the pharmacy and requested that the diagnosis be printed on the MAR and the prescription labels. The corrections will be made with the next med refill or before. 3/1/2022 03/01/2022 Implemented
SIN-00070844 Renewal 10/28/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(9)The physical examination, dated 1/21/14, for Individual #1, date of birth 10/30/68, does not include a prostate examination.The physical examination shall include: A prostate examination for men 40 years of age or older. I accepted the county's physical form without noticing that it did not call out for a prostate exam for men 40 or older. From this point on, Oak Manor will only accept physicals completed on our own physical form as this form does require a prostate exam for men 40 and onder. [Prostate examination for Individual #1 was completed on 11/20/14. (CHG 11/24/14)] 11/17/2014 Implemented
SIN-00042335 Renewal 10/01/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(c)The incident of abuse for individual #1 was not reported within 24 hours. The incident, number 4580155, occurred on 3/10/12 and the incident was reported on 3/12/12. Partially implemented - adequate progress - MZ - 2/11/2013. (c) The home shall orally notify the county mental retardation program of the county in which the home is located, the funding agency and the appropriate regional office of mental retardation, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs. This staff was retrained on 3/12/12 by the program Supervisor. All staff are trained upon hire and annually by the CEO and Program Supervisors. All staff were retrained on this subject at the September Employee meeting by the CEO. This staff thought that since this incident involved a resident's "friend" complaining that he called her too much that it was not a "serious" incident. All staff have been trained that this is not their call to make. Any incident involving the police, must be reported to the point person immediately. We have had no other similar incidents, since the, but 3 incidents showing appropriate reporting times are: 5127146, 5281313 and 5166445. 01/30/2013 Implemented
6400.72(b)The bedroom for individual #2 has a 1 square inch splintered hole on the inside of the door.Fully implemented - MZ - 2/13/2013.(b) Screens, windows and doors shall be in good repair. This non-compliace was corrected on site. The correction was seen and reviewed by the licensing inspectors on 10/2/12. Oak Manor has a procedure of quarterly inspections by the program Supervisors, bi-annual inspecitons by the safety committee and an annual inspection by the CEO. Since we don't know when the hole was made we don't know if any one missed it, but it could have been missed by all of us. Therefore, the entire managemnt team, reviewed our incpection procedures at our October Managemnet meeting to ensure more thorough inspections are completed. 01/30/2013 Implemented
SIN-00236328 Renewal 12/12/2023 Compliant - Finalized
SIN-00184472 Renewal 03/09/2021 Compliant - Finalized
SIN-00167319 Renewal 12/05/2019 Compliant - Finalized
SIN-00127868 Renewal 01/04/2018 Compliant - Finalized
SIN-00071558 Renewal 12/02/2015 Compliant - Finalized
SIN-00055629 Renewal 11/06/2013 Compliant - Finalized