Deficiency Records for The Oaks at Lakewood
Updated as of September 01, 2020
This is not the most recent data for The Oaks at Lakewood. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-22 | 2020-02-28 | 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 |
| 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 |
| 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 | Y |
| 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 |
| 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 | 2019-09-26 | 2019-10-18 | Y |
| 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 | 2019-04-05 | 2019-05-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-05 | 2019-05-03 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-19 | 2018-12-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-10-11 | 2018-11-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-11 | 2018-11-16 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-10-11 | 2018-11-16 | 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 | 2018-10-11 | 2018-11-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-10-11 | 2018-11-16 | 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 | 2018-10-11 | 2018-11-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-10-11 | 2018-11-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-11 | 2018-11-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-10-11 | 2018-11-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-11 | 2018-11-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-11 | 2018-11-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-10-11 | 2018-11-16 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-11 | 2018-11-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-11 | 2018-11-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-11 | 2018-11-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-11 | 2018-11-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-11 | 2018-11-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-10-11 | 2018-11-16 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2018-10-11 | 2018-11-16 | 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 | 2018-10-11 | 2018-11-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-11 | 2018-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-11 | 2018-11-16 | N |
| Respond appropriately to all alleged violations. | Health | 2018-09-20 | 2018-10-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-26 | 2018-08-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-02-06 | 2018-03-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-02-06 | 2018-03-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-02-06 | 2018-03-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-02-06 | 2018-03-09 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2018-02-06 | 2018-03-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-06 | 2018-03-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-16 | 2018-01-23 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-21 | 2017-12-20 | Y |
| Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing. | Health | 2017-10-26 | 2017-12-02 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-10-26 | 2017-12-02 | Y |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-10-26 | 2017-12-02 | Y |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2017-10-26 | 2017-12-02 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-26 | 2017-12-02 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-10-26 | 2017-12-02 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-10-26 | 2017-12-02 | Y |
| Provide or obtain dental services for each resident. | Health | 2017-10-26 | 2017-12-02 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-10-26 | 2017-12-02 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-09-06 | 2017-10-04 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-09-06 | 2017-10-04 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-09-06 | 2017-10-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-06 | 2017-10-04 | Y |
| 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compensation. | Health | 2017-09-06 | 2017-10-04 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-19 | 2017-08-23 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-05-18 | 2017-06-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-05-18 | 2017-06-22 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-18 | 2017-06-22 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-05-18 | 2017-06-22 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-05-18 | 2017-06-22 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-05-18 | 2017-06-22 | Y |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-05-18 | 2017-06-22 | Y |
| Operate and provide services according to Federal, State, and local laws and professional standards. | Health | 2017-05-18 | 2017-06-22 | Y |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-05-04 | 2017-05-27 | Y |
