Deficiency Records for Three Oaks Health Services
Updated as of August 01, 2022
This is not the most recent data for Three Oaks Health Services. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-06-29 | 2020-07-22 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-10-28 | 2019-11-15 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2019-10-28 | 2019-11-15 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-10-28 | 2019-11-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-28 | 2019-11-15 | Y |
| 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 | 2019-10-28 | 2019-11-15 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-28 | 2019-11-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-28 | 2019-11-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-28 | 2019-11-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-10-28 | 2019-11-15 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-10-28 | 2019-11-15 | 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 | 2019-10-23 | 2019-11-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-23 | 2019-11-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-04 | 2019-09-27 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-09-04 | 2019-09-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-04 | 2019-07-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-04 | 2018-11-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-04 | 2018-11-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-04 | 2018-11-04 | 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 | 2018-10-04 | 2018-11-04 | 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 | 2018-10-04 | 2018-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-04 | 2018-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-04 | 2018-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-04 | 2018-11-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-10-04 | 2018-11-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-04 | 2018-11-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-04 | 2018-11-04 | N |
