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Deficiency Records for Three Oaks Health Services
A list of the most recent deficiencies for Three Oaks Health Services. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Three Oaks Health Services. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-04 | 2024-02-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-01 | 2023-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-01 | 2023-11-17 | 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 | 2023-10-31 | 2023-11-17 | 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 | 2023-10-31 | 2023-11-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-31 | 2023-11-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-31 | 2023-11-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-31 | 2023-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-14 | 2022-10-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-14 | 2022-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-14 | 2022-10-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-14 | 2022-10-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-14 | 2022-10-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-14 | 2022-10-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-14 | 2022-10-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-07-15 | 2021-08-13 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-15 | 2021-08-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-15 | 2021-08-13 | 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 | 2021-07-15 | 2021-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-08-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-08-13 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-12 | 2021-08-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-07-12 | 2021-08-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-12 | 2021-08-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-12 | 2021-08-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-12 | 2021-08-13 | N |
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