Deficiency Records for West Oaks Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for West Oaks Nursing and Rehabilitation 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 necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-11-13 | 2023-12-26 | Y |
| 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 | 2023-08-31 | 2023-10-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-31 | 2023-10-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-31 | 2023-10-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-31 | 2023-10-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-03 | 2023-10-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-03 | 2023-10-03 | 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 | 2023-09-03 | 2023-10-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-03 | 2023-10-03 | 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 | 2023-09-03 | 2023-10-03 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-09-03 | 2023-10-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-03 | 2023-10-03 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-09-03 | 2023-10-03 | 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 | 2023-08-24 | 2023-09-22 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-07-05 | 2023-08-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-29 | 2023-04-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-12 | 2022-12-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-12 | 2022-12-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-11 | 2022-10-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-14 | 2022-08-05 | N |
| Provide activities to meet all resident's needs. | Health | 2022-07-14 | 2022-08-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-14 | 2022-08-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-14 | 2022-08-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-22 | 2022-03-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-30 | 2022-01-20 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-12-30 | 2022-01-20 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-10-14 | 2021-11-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-14 | 2021-11-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-17 | 2021-07-25 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-17 | 2021-07-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-06-17 | 2021-07-25 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2021-06-17 | 2021-07-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-06-17 | 2021-07-25 | 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 | 2021-06-17 | 2021-07-25 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-17 | 2021-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-17 | 2021-07-25 | 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 | 2021-06-17 | 2021-07-25 | N |
| Post nurse staffing information every day. | Health | 2021-06-17 | 2021-07-25 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-06-17 | 2021-07-25 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-06-17 | 2021-07-25 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-06-17 | 2021-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-17 | 2021-07-25 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-06-17 | 2021-07-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-17 | 2021-07-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-21 | 2021-07-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-02 | 2021-03-03 | Y |
