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Deficiency Records for Five Oaks Rehabilitation and Care Center
A list of the most recent deficiencies for Five Oaks Rehabilitation and Care 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 Five Oaks Rehabilitation and Care 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-12 | 2024-01-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-12 | 2024-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-12 | 2024-01-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-12 | 2024-01-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-12 | 2024-01-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-12 | 2024-01-03 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-10-12 | 2024-01-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-12 | 2024-01-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-12 | 2024-01-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-09-14 | 2023-09-27 | 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 | 2023-09-14 | 2023-09-27 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-14 | 2023-09-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-14 | 2023-09-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-15 | 2023-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-15 | 2023-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-16 | 2023-04-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-02 | 2023-03-15 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-02 | 2023-03-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-21 | 2022-12-04 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-10-21 | 2022-12-04 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-21 | 2022-09-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-07-21 | 2022-09-04 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-07-21 | 2022-09-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-21 | 2022-09-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-21 | 2022-09-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-21 | 2022-09-04 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-05-16 | 2022-07-20 | 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 | 2022-05-16 | 2022-07-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-16 | 2022-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-16 | 2022-07-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-16 | 2022-07-20 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-16 | 2022-07-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-16 | 2022-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-16 | 2022-07-20 | Y |
| 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 | 2022-05-16 | 2022-07-20 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-05-16 | 2022-07-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-16 | 2022-06-09 | N |
| Use approved construction type or materials. | Fire Safety | 2019-12-17 | 2020-01-31 | 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 | 2019-12-17 | 2020-01-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-17 | 2020-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-17 | 2020-01-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-11-15 | 2019-12-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-15 | 2019-12-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-15 | 2019-12-13 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-11-15 | 2019-12-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-11-15 | 2019-12-13 | N |
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