A list of the most recent deficiencies for The Oaks at Northpointe Woods. 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? |
|---|---|---|---|---|
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2023-09-19 | 2023-10-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-28 | 2023-07-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-28 | 2023-07-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-28 | 2023-07-25 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-25 | 2023-03-01 | 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 | 2023-01-25 | 2023-03-01 | 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 | 2023-01-25 | 2023-03-01 | 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 | 2023-01-25 | 2023-03-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-25 | 2023-03-01 | N |
| Provide appropriate foot care. | Health | 2023-01-25 | 2023-03-01 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-01-25 | 2023-03-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-25 | 2023-03-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-30 | 2023-03-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-03-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-30 | 2023-03-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-30 | 2023-03-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-23 | 2022-03-22 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-02-23 | 2022-03-22 | 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 | 2022-02-23 | 2022-03-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-23 | 2022-03-22 | N |
| 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 | 2022-02-23 | 2022-03-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-23 | 2022-03-22 | N |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2022-02-23 | 2022-03-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-02-23 | 2022-03-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-23 | 2022-03-22 | 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 | 2022-02-16 | 2022-03-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-16 | 2022-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-24 | 2021-05-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-18 | 2021-04-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-18 | 2021-03-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-30 | 2020-03-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-30 | 2020-03-06 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-30 | 2020-03-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-12-30 | 2020-03-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-12-30 | 2020-01-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-12-30 | 2020-01-23 | 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 | 2019-12-30 | 2020-01-23 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-12-30 | 2020-01-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-30 | 2020-01-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-30 | 2020-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-30 | 2020-01-23 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-12-30 | 2020-01-23 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-12-30 | 2020-01-23 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-12-30 | 2020-01-23 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-12-30 | 2020-01-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-12-30 | 2020-01-23 | 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 | 2019-12-30 | 2020-01-23 | 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 | 2019-12-30 | 2020-01-23 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-12-30 | 2020-01-23 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2019-12-30 | 2020-01-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-30 | 2020-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-30 | 2020-01-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-30 | 2020-01-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-12-30 | 2020-01-23 | N |
| 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 | 2019-12-17 | 2020-01-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-17 | 2020-01-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-17 | 2020-01-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-17 | 2020-01-23 | N |
