Deficiency Records for West Oaks Senior Care and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for West Oaks Senior Care and Rehab 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2023-12-05 | 2023-12-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-05 | 2023-12-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-18 | 2023-09-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-27 | 2023-08-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-27 | 2023-08-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-27 | 2023-08-15 | N |
| Provide or obtain dental services for each resident. | Health | 2023-07-27 | 2023-08-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-27 | 2023-08-15 | N |
| Keep all essential equipment working safely. | Health | 2023-07-27 | 2023-08-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-25 | 2023-08-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-18 | 2023-01-25 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-18 | 2023-01-25 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-05-26 | 2022-06-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-05-26 | 2022-06-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-26 | 2022-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-26 | 2022-06-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-26 | 2022-06-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-26 | 2022-06-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-26 | 2022-06-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-26 | 2022-06-22 | N |
| Keep all essential equipment working safely. | Health | 2022-05-26 | 2022-06-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-26 | 2022-06-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-26 | 2022-06-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-22 | 2021-10-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-22 | 2021-10-13 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-22 | 2021-10-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-22 | 2021-10-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-14 | 2021-05-06 | 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 | 2021-04-14 | 2021-05-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-14 | 2021-05-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-14 | 2021-05-06 | 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 | 2021-04-14 | 2021-05-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-14 | 2021-05-06 | 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 | 2021-04-14 | 2021-05-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-14 | 2021-05-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-14 | 2021-05-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-14 | 2021-05-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-14 | 2021-05-06 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-04-15 | 2021-05-06 | 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 | 2021-04-15 | 2021-05-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-15 | 2021-05-06 | N |
