A list of the most recent deficiencies for The Oaks. 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? |
|---|---|---|---|---|
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-11-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-11 | 2023-11-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-11 | 2023-11-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-15 | 2023-10-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-09-15 | 2023-10-04 | 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 | 2023-09-15 | 2023-10-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-15 | 2023-10-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-15 | 2023-10-04 | 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 | 2023-09-15 | 2023-10-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-15 | 2023-10-04 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-15 | 2023-10-04 | 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 | 2022-08-02 | 2022-08-19 | 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 | 2022-08-02 | 2022-08-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-07-08 | 2022-08-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-07-08 | 2022-08-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-08 | 2022-08-08 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-07-08 | 2022-08-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-07-08 | 2022-08-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-08 | 2022-08-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-08 | 2022-08-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-08 | 2022-08-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-07-08 | 2022-08-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-08 | 2022-08-08 | Y |
| 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 | 2022-07-08 | 2022-08-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-08 | 2022-08-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-08 | 2022-08-08 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2022-07-08 | 2022-08-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-24 | 2021-09-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-24 | 2021-09-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-23 | 2021-09-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-23 | 2021-09-24 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-23 | 2021-09-24 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-07-23 | 2021-09-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-23 | 2021-09-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-23 | 2021-09-24 | 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 | 2021-07-23 | 2021-09-24 | 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 | 2021-07-23 | 2021-09-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-23 | 2021-09-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-23 | 2021-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-23 | 2021-09-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-23 | 2021-09-24 | Y |
| 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 | 2021-07-23 | 2021-09-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-23 | 2021-09-24 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-17 | 2021-09-13 | N |
