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Deficiency Records for Highland Oaks Health Center
A list of the most recent deficiencies for Highland Oaks Health 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 Highland Oaks Health 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-06 | 2024-08-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-06 | 2024-08-15 | Y |
| Keep all essential equipment working safely. | Health | 2024-08-06 | 2024-08-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-08-06 | 2024-08-15 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-04-10 | 2024-04-24 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-12-18 | 2024-01-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-12-18 | 2024-01-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-18 | 2024-01-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-18 | 2024-01-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-18 | 2024-01-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-12-18 | 2024-01-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-18 | 2024-01-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-18 | 2024-01-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-18 | 2024-01-12 | 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 | 2023-12-18 | 2024-01-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-18 | 2024-01-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-18 | 2024-01-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-18 | 2024-01-12 | 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 | 2023-12-18 | 2024-01-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-18 | 2024-01-12 | 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 | 2023-12-18 | 2024-01-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-18 | 2024-01-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-12-18 | 2024-01-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-18 | 2024-01-12 | N |
| Post nurse staffing information every day. | Health | 2023-12-18 | 2024-01-12 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-12-18 | 2024-01-12 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-12-18 | 2024-01-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-18 | 2024-01-12 | 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 | 2023-12-18 | 2024-01-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-18 | 2024-01-12 | 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 | 2023-12-18 | 2024-01-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-18 | 2024-01-12 | 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 | 2023-12-18 | 2024-01-12 | N |
| Provide or obtain dental services for each resident. | Health | 2023-12-18 | 2024-01-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-18 | 2024-01-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-18 | 2024-01-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-18 | 2024-01-12 | 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 | 2023-12-06 | 2024-01-12 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-12-06 | 2024-01-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-06 | 2024-01-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-06 | 2024-01-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-12-06 | 2024-01-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-04-19 | 2022-05-18 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-04-19 | 2022-05-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-19 | 2022-05-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-19 | 2022-05-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-19 | 2022-05-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-19 | 2022-05-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-19 | 2022-05-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-19 | 2022-05-18 | 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 | 2022-04-19 | 2022-05-18 | 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 | 2022-04-19 | 2022-05-18 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2022-04-19 | 2022-05-18 | 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 | 2022-04-11 | 2022-05-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-04-11 | 2022-05-18 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-04-11 | 2022-05-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-11 | 2022-05-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-11 | 2022-05-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-11 | 2022-05-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-11 | 2022-05-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-11 | 2022-05-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-18 | 2021-10-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-28 | 2019-10-02 | 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 | 2019-08-28 | 2019-10-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-28 | 2019-10-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-28 | 2019-10-02 | 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 | 2019-08-28 | 2019-10-02 | 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 | 2019-08-28 | 2019-10-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-08-28 | 2019-10-02 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-08-28 | 2019-10-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-27 | 2019-10-02 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-08-27 | 2019-10-02 | 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 | 2024-09-24 | Not Fixed | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-06 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-06 | Not Fixed | N |
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