A list of the most recent deficiencies for West Oaks Nursing and Rehab 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? |
|---|---|---|---|---|
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-30 | 2023-12-22 | 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 | 2023-11-28 | 2023-12-19 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-28 | 2023-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-28 | 2023-12-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-28 | 2023-12-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-30 | 2023-12-14 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-09-22 | 2022-10-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-22 | 2022-10-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-20 | 2022-10-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-20 | 2022-10-14 | 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 | 2021-07-09 | 2021-07-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-09 | 2021-07-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-09 | 2021-07-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-09 | 2021-07-30 | 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 | 2021-07-09 | 2021-07-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-09 | 2021-07-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-09 | 2021-07-30 | 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 | 2021-07-06 | 2021-07-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-06 | 2021-07-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-06 | 2021-07-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-04 | 2021-06-25 | Y |
