A list of the most recent deficiencies for Country Oaks Care Center. 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? |
|---|---|---|---|---|
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-12-26 | 2024-01-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-26 | 2024-01-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-30 | 2023-06-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-30 | 2023-06-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-30 | 2023-06-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-27 | 2023-05-17 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-27 | 2023-05-08 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-06 | 2023-03-30 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-24 | 2023-03-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-24 | 2023-03-17 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-02-24 | 2023-03-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-24 | 2023-03-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-24 | 2023-03-17 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-02-24 | 2023-03-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-24 | 2023-03-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-24 | 2023-03-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-24 | 2023-03-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-24 | 2023-03-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-24 | 2023-03-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-24 | 2023-03-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-24 | 2023-03-17 | 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 | 2023-02-24 | 2023-03-17 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-02-24 | 2023-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-24 | 2023-03-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-02-24 | 2023-03-17 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-02-24 | 2023-03-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-24 | 2023-03-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-27 | 2023-03-17 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-02-27 | 2023-03-17 | 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 | 2023-02-27 | 2023-03-17 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-02-27 | 2023-03-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-27 | 2023-03-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-27 | 2023-03-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-27 | 2023-03-17 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2023-02-27 | 2023-03-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-03 | 2023-03-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-03 | 2023-03-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-14 | 2023-03-08 | Y |
| 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 | 2023-02-14 | 2023-03-08 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-14 | 2023-03-08 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-02-14 | 2023-03-08 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-02-14 | 2023-03-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-11 | 2023-03-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-11 | 2023-03-08 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-11-01 | 2022-12-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-13 | 2022-11-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-13 | 2022-11-12 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-10-13 | 2022-11-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-13 | 2022-11-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-17 | 2022-09-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-17 | 2022-09-16 | Y |
| 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 | 2022-08-17 | 2022-09-16 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-08-17 | 2022-09-16 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-08-16 | 2022-09-07 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-08-05 | 2022-08-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-08-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-03 | 2022-08-08 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-12 | 2022-05-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-31 | 2022-04-30 | 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 | 2022-03-31 | 2022-04-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-10 | 2022-03-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-17 | 2022-03-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-18 | 2022-03-20 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-18 | 2022-03-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-16 | 2022-03-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-16 | 2022-03-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-16 | 2022-03-17 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-16 | 2022-03-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-16 | 2022-03-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-21 | 2022-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-21 | 2022-02-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-21 | 2022-02-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-27 | 2021-08-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-21 | 2021-08-13 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-09-16 | 2019-11-12 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-09-16 | 2019-11-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-16 | 2019-11-12 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-09-16 | 2019-11-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-16 | 2019-11-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-16 | 2019-11-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-16 | 2019-11-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-16 | 2019-11-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-16 | 2019-11-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-09-16 | 2019-11-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-16 | 2019-11-12 | 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 | 2019-09-16 | 2019-11-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-16 | 2019-11-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-16 | 2019-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-16 | 2019-11-12 | N |
| Keep all essential equipment working safely. | Health | 2019-09-16 | 2019-11-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-16 | 2019-11-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-22 | 2019-10-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-22 | 2019-10-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-09-22 | 2019-10-10 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-09-22 | 2019-10-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-22 | 2019-10-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-20 | 2018-11-06 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2018-09-20 | 2018-11-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-20 | 2018-11-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-20 | 2018-11-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-09-20 | 2018-11-06 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-09-20 | 2018-11-06 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-09-20 | 2018-11-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-09-20 | 2018-11-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-20 | 2018-11-06 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-09-20 | 2018-11-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-09-20 | 2018-11-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-09-27 | 2018-10-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-09-27 | 2018-10-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-09-27 | 2018-10-22 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-09-27 | 2018-10-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-09-27 | 2018-10-22 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2018-09-27 | 2018-10-22 | N |
| Meet other general requirements. | Fire Safety | 2018-09-27 | 2018-10-22 | N |
