A list of the most recent deficiencies for The Oaks Healthcare 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-27 | 2023-12-11 | 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 | 2023-10-27 | 2023-12-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-27 | 2023-12-11 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-10-27 | 2023-12-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-27 | 2023-12-11 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-10-27 | 2023-12-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-27 | 2023-12-11 | 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 | 2023-10-27 | 2023-12-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-27 | 2023-12-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-27 | 2023-12-11 | 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 | 2022-07-13 | 2022-08-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-13 | 2022-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-13 | 2022-08-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-07-13 | 2022-08-15 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-13 | 2022-08-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-13 | 2022-08-15 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-13 | 2022-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-13 | 2022-08-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-13 | 2022-08-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-07-13 | 2022-08-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-05 | 2020-01-10 | 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 | 2020-01-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-05 | 2020-01-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-12-05 | 2020-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-05 | 2020-01-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-12-05 | 2020-01-10 | 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 | 2019-12-05 | 2020-01-10 | 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 | 2020-01-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-12-05 | 2020-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-05 | 2020-01-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-29 | 2018-12-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-10-29 | 2018-12-02 | 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 | 2018-10-29 | 2018-11-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-29 | 2018-11-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-10-29 | 2018-10-30 | N |
