A list of the most recent deficiencies for The Oaks-Brevard. 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? |
|---|---|---|---|---|
| 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 | 2023-09-20 | 2023-10-06 | 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 | 2023-09-20 | 2023-10-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-20 | 2023-10-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-20 | 2023-10-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-20 | 2023-10-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-20 | 2023-10-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-20 | 2023-10-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-17 | 2023-09-06 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-17 | 2023-09-06 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-17 | 2023-09-06 | 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 | 2023-08-17 | 2023-09-06 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-08-17 | 2023-09-06 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-17 | 2023-09-06 | Y |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2023-08-17 | 2023-09-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-17 | 2023-09-06 | 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 | 2023-08-17 | 2023-09-06 | 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 | 2023-08-17 | 2023-09-06 | 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 | 2023-08-17 | 2023-09-06 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-17 | 2023-09-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-09-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-17 | 2023-07-27 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-03 | 2022-03-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-03 | 2022-03-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-07 | 2022-02-02 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-01-07 | 2022-02-02 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-01-07 | 2022-02-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-07 | 2022-02-02 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-07 | 2022-02-02 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-01-07 | 2022-02-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-07 | 2022-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-02-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-16 | 2021-07-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-16 | 2021-06-29 | Y |
| Use approved construction type or materials. | Fire Safety | 2020-01-30 | 2020-03-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-30 | 2020-03-15 | 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 | 2020-01-30 | 2020-03-15 | 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 | 2020-01-30 | 2020-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-30 | 2020-03-15 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2020-01-30 | 2020-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-30 | 2020-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-30 | 2020-03-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-30 | 2020-03-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-30 | 2020-03-15 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-01-30 | 2020-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-30 | 2020-03-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-01-30 | 2020-03-15 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-01-10 | 2020-02-07 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-01-10 | 2020-02-07 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-01-10 | 2020-02-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-10 | 2020-02-07 | 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 | 2020-01-10 | 2020-02-07 | N |
