A list of the most recent deficiencies for Thousand Oaks Post Acute, 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? |
|---|---|---|---|---|
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-11-08 | 2023-11-21 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-08-02 | 2023-08-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-05 | 2023-05-17 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-03-09 | 2023-03-21 | Y |
| 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 | 2022-09-10 | 2022-09-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-16 | 2022-07-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-18 | 2021-12-20 | 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 | 2021-11-18 | 2021-12-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-11-18 | 2021-12-20 | 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 | 2021-11-18 | 2021-12-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-18 | 2021-12-20 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2021-11-18 | 2021-12-20 | 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 | 2021-11-18 | 2021-12-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-18 | 2021-12-20 | 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 | 2021-11-18 | 2021-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-18 | 2021-12-20 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-22 | 2021-12-07 | 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 | 2021-11-22 | 2021-12-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-22 | 2021-12-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-22 | 2021-12-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-22 | 2021-12-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-22 | 2021-12-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-11-22 | 2021-12-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-22 | 2021-12-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-04 | 2021-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-04 | 2021-12-03 | Y |
| Use approved construction type or materials. | Fire Safety | 2020-02-06 | 2020-02-24 | 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 | 2020-02-06 | 2020-02-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-06 | 2020-02-24 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-02-06 | 2020-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-06 | 2020-02-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-06 | 2020-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-06 | 2020-02-24 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-12-05 | 2020-01-03 | 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 | 2019-12-05 | 2020-01-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-05 | 2020-01-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-05 | 2020-01-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-05 | 2020-01-03 | 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 | 2019-12-05 | 2020-01-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-05 | 2020-01-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-05 | 2020-01-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-05 | 2020-01-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-05 | 2020-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-02-07 | 2019-02-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-07 | 2019-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-07 | 2019-02-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-07 | 2019-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-07 | 2019-02-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-26 | 2019-02-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-12-26 | 2019-02-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-12-26 | 2019-02-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-26 | 2019-02-07 | 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 | 2018-12-26 | 2019-02-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-26 | 2019-02-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-12-26 | 2019-02-07 | N |
| Provide activities to meet all resident's needs. | Health | 2018-12-26 | 2019-02-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-26 | 2019-02-07 | 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 | 2018-12-26 | 2019-02-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-12-26 | 2019-02-07 | 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 | 2018-12-26 | 2019-02-07 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-12-26 | 2019-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-26 | 2019-02-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-26 | 2019-02-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-26 | 2019-02-07 | N |
| Keep all essential equipment working safely. | Health | 2018-12-26 | 2019-02-07 | N |
