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Deficiency Records for Oakhurst Health and Rehabilitation
A list of the most recent deficiencies for Oakhurst Health and Rehabilitation. 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 Oakhurst Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-02-22 | 2024-04-15 | N |
| 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 | 2024-02-22 | 2024-04-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-22 | 2024-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-22 | 2024-04-15 | 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 | 2024-02-22 | 2024-04-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-22 | 2024-04-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-22 | 2024-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-22 | 2024-04-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-22 | 2024-04-15 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-02-22 | 2024-04-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-02-22 | 2024-04-15 | 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 | 2024-02-22 | 2024-04-15 | 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 | 2024-02-22 | 2024-04-15 | 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 | 2024-02-22 | 2024-04-15 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2024-02-22 | 2024-04-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-22 | 2024-04-15 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-02-22 | 2024-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-06 | 2021-11-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-10-06 | 2021-11-02 | N |
| 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 | 2021-10-06 | 2021-11-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-06 | 2021-11-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-06 | 2021-11-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-10-06 | 2021-11-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-06 | 2021-11-02 | 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 | 2021-10-06 | 2021-11-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-06 | 2021-11-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-06 | 2021-11-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-06 | 2021-11-02 | 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 | 2021-10-06 | 2021-11-02 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-10-06 | 2021-11-02 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-10-06 | 2021-11-02 | 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 | 2021-10-12 | 2021-11-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-10-12 | 2021-11-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-12 | 2021-11-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-12 | 2021-11-02 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-06 | 2021-11-02 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-10-06 | 2021-11-02 | Y |
| Develop a communication plan. | Fire Safety | 2021-10-06 | 2021-11-02 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2021-10-06 | 2021-11-02 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2021-10-06 | 2021-11-02 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2021-10-06 | 2021-11-02 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2021-10-06 | 2021-11-02 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-06 | 2021-11-02 | Y |
| 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 | 2019-04-03 | 2019-05-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-03 | 2019-05-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-03 | 2019-05-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-03 | 2019-05-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-03 | 2019-05-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-21 | 2019-05-01 | 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 | 2019-03-21 | 2019-05-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-03-21 | 2019-05-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-21 | 2019-05-01 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-21 | 2019-05-01 | 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 | 2019-03-21 | 2019-05-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-03-21 | 2019-05-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-21 | 2019-05-01 | 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 | 2019-03-21 | 2019-05-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-21 | 2019-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-21 | 2019-05-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-03-21 | 2019-05-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-21 | 2019-05-01 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-03-21 | 2019-05-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-21 | 2019-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-21 | 2019-05-01 | N |
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