A list of the most recent deficiencies for The Oaks at Lakewood. 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? |
|---|---|---|---|---|
| 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 | 2023-12-08 | 2024-01-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-08 | 2024-01-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-08 | 2024-01-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-08 | 2024-01-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-08 | 2024-01-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-08 | 2024-01-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-12-08 | 2024-01-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-08 | 2024-01-12 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-12-08 | 2024-01-12 | N |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2023-12-08 | 2024-01-12 | N |
| Respond appropriately to all alleged violations. | Health | 2023-12-08 | 2024-01-12 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-05 | 2024-01-05 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-12-05 | 2024-01-05 | 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 | 2023-12-05 | 2024-01-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-05 | 2023-12-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-05 | 2023-12-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-05 | 2022-12-16 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-14 | 2022-11-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-19 | 2022-10-28 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-09-19 | 2022-10-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-19 | 2022-10-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-09-19 | 2022-10-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-19 | 2022-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-19 | 2022-10-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-19 | 2022-10-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-19 | 2022-10-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-19 | 2022-10-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-19 | 2022-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-19 | 2022-10-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-19 | 2022-10-28 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Develop a communication plan. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-14 | 2022-10-19 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-26 | 2021-08-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-26 | 2021-08-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-26 | 2021-08-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-26 | 2021-08-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-26 | 2021-08-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-10-30 | 2019-12-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-10-30 | 2019-12-18 | 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 | 2019-10-30 | 2019-12-18 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-30 | 2019-12-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-30 | 2019-12-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-30 | 2019-12-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-10-30 | 2019-12-18 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-30 | 2019-12-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-30 | 2019-12-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-30 | 2019-12-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-30 | 2019-12-18 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-10-30 | 2019-12-18 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-10-30 | 2019-12-18 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-10-30 | 2019-12-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-30 | 2019-12-18 | N |
| Post nurse staffing information every day. | Health | 2019-10-30 | 2019-12-18 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-10-30 | 2019-12-18 | 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 | 2019-10-30 | 2019-12-18 | 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 | 2019-10-30 | 2019-12-18 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-10-30 | 2019-12-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-30 | 2019-12-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-30 | 2019-12-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-30 | 2019-12-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-30 | 2019-12-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-24 | 2019-11-22 | N |
