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Deficiency Records for West Oaks Senior Care and Rehab Center
A list of the most recent deficiencies for West Oaks Senior Care and Rehab Center. 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 West Oaks Senior Care 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-25 | 2024-07-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-06-25 | 2024-07-12 | 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 | 2024-06-25 | 2024-07-12 | 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 | 2024-06-25 | 2024-07-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-25 | 2024-07-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-25 | 2024-07-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-06-25 | 2024-07-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-06-25 | 2024-07-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-06-25 | 2024-07-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-06-25 | 2024-07-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-06-25 | 2024-07-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-07 | 2024-05-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-05 | 2023-12-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-05 | 2023-12-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-18 | 2023-09-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-27 | 2023-08-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-27 | 2023-08-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-27 | 2023-08-15 | N |
| Provide or obtain dental services for each resident. | Health | 2023-07-27 | 2023-08-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-27 | 2023-08-15 | N |
| Keep all essential equipment working safely. | Health | 2023-07-27 | 2023-08-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-25 | 2023-08-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-18 | 2023-01-25 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-01-18 | 2023-01-25 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-05-26 | 2022-06-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-05-26 | 2022-06-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-26 | 2022-06-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-26 | 2022-06-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-26 | 2022-06-22 | 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 | 2022-05-26 | 2022-06-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-26 | 2022-06-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-26 | 2022-06-22 | N |
| Keep all essential equipment working safely. | Health | 2022-05-26 | 2022-06-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-26 | 2022-06-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-26 | 2022-06-22 | Y |
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