General Information: THE OAKS OF BREVARD
Nursing home name THE OAKS OF BREVARD
Address300 MORRIS ROAD
BREVARD, NC 28712
Phone number (828) 877-4020
Located within a hospital No
Type of ownership For profit - Corporation
Owner operates multiple homesYes
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityNo
Resident and family councils Resident
Certified number of beds 120
Total number of residents 84
Perc of occupied beds 70
Sprinkler status Yes
Number of Facility Reported Incidents0
Number of Substantiated Complaints22
Number of Fines0
Total Amount of Fines$0
Total Number of Penalties0
Total Number of Penalties0
Ratings Summary: THE OAKS OF BREVARD
Overall rating 2
2
Nursing Home Staffing 4
4
Registered Nurses only 5
5
Health Inspections 1
1
Quality Measures 5
5
Nursing Home Staffing Info: THE OAKS OF BREVARD
National AverageNorth Carolina AverageTHE OAKS OF BREVARD
Overall staff rating NA NA 4
4
Registered Nurses only rating NANA 5
5
Total Number of Residents NA NA 84
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 4.09 hours 4.14 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.65 hours 1.75 hours
Registered Nurses Hours per Residents per Day 0.81 hours 0.77 hours 1.1 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.88 hours 0.65 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.44 hours 2.39 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.11 hours 0.13 hours
Health Survey: THE OAKS OF BREVARD
Heath Survey Summary on 2013-07-11
Total Number of Health Deficiencies 2
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Heath Survey Summary on 2012-04-27
Total Number of Health Deficiencies 16
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Heath Survey Summary on 2011-06-23
Total Number of Health Deficiencies 10
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Health Survey Details: THE OAKS OF BREVARD
Inspection Results: 07/11/2013
Corrected Deficiency Scope and Severity
08/08/2013 Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated/Minimal harm or potential for actual harm
08/08/2013 Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated/Minimal harm or potential for actual harm
Inspection Results: 04/27/2012
Corrected Deficiency Scope and Severity
05/25/2012 Store, cook, and serve food in a safe and clean way. Pattern/Minimal harm or potential for actual harm
05/25/2012 Provide food in a way that meets a resident's needs. Isolated/Minimal harm or potential for actual harm
05/25/2012 Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated/Minimal harm or potential for actual harm
05/25/2012 Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Pattern/Minimal harm or potential for actual harm
05/25/2012 Provide housekeeping and maintenance services. Isolated/Minimal harm or potential for actual harm
05/25/2012 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Minimal harm or potential for actual harm
05/25/2012 Ensure services provided by the nursing facility meet professional standards of quality. Isolated/Minimal harm or potential for actual harm
05/25/2012 Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated/Minimal harm or potential for actual harm
05/25/2012 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm
05/25/2012 Operate and provide services according to Federal, State, and local laws and professional standards. Pattern/Potential for minimal harm
05/25/2012 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern/Minimal harm or potential for actual harm
05/25/2012 Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated/Minimal harm or potential for actual harm
05/25/2012 Provide special eating equipment and utensils for each resident who needs them. Isolated/Minimal harm or potential for actual harm
05/25/2012 Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated/Minimal harm or potential for actual harm
05/25/2012 Develop policies and procedures for influenza and pneumococcal immunizations. Isolated/Minimal harm or potential for actual harm
05/25/2012 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
Inspection Results: 06/23/2011
Corrected Deficiency Scope and Severity
07/21/2011 Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated/Minimal harm or potential for actual harm
07/21/2011 Store, cook, and serve food in a safe and clean way. Pattern/Minimal harm or potential for actual harm
07/21/2011 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated/Minimal harm or potential for actual harm
07/21/2011 Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated/Minimal harm or potential for actual harm
07/21/2011 Ensure services provided by the nursing facility meet professional standards of quality. Isolated/Minimal harm or potential for actual harm
07/21/2011 Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated/Minimal harm or potential for actual harm
07/21/2011 Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated/Minimal harm or potential for actual harm
07/21/2011 Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated/Minimal harm or potential for actual harm
07/21/2011 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated/Minimal harm or potential for actual harm
07/21/2011 Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm

Fire Safety Survey: THE OAKS OF BREVARD
Fire Safety Survey Summary on 2013-08-01
Total Number of Fire SafetyDeficiencies 2
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2012-05-17
Total Number of Fire SafetyDeficiencies 1
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2011-07-19
Total Number of Fire SafetyDeficiencies 2
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Fire Safety Survey: THE OAKS OF BREVARD
Fire Safety Survey Results: 08/01/2013
Corrected Deficiency Severity
08/17/2013 Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. Isolated/Minimal harm or potential for actual harm
08/17/2013 Exits that are accessible at all times. Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Results: 05/17/2012
Corrected Deficiency Severity
07/01/2012 An approved automatic sprinkler system connected to the fire alarm system. Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Results: 07/19/2011
Corrected Deficiency Severity
09/02/2011 Automatic sprinkler systems that have been maintained in working order. Isolated/Minimal harm or potential for actual harm
09/02/2011 Weekly inspections and monthly testing of generators. Isolated/Minimal harm or potential for actual harm

Resident Complaints: THE OAKS OF BREVARD
Date Complaint Substantiated: 12/19/2011
CorrectedCategoryDeficiencySeverity
01/16/2012Provide medically-related social services to help each resident achieve the highest possible quality of life. D
Date Complaint Substantiated: 07/19/2011
CorrectedCategoryDeficiencySeverity
08/05/2011Ensure services provided by the nursing facility meet professional standards of quality. D
08/05/2011Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. D

Quality Measures: THE OAKS OF BREVARD
Quality Measures National Average North Carolina Average THE OAKS OF BREVARD
Overall quality rating NA NA 5
5
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 19.2% 8.3%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 9.5% 2.5%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 7.0% 2.4%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 8.9% 7.9%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 52.6% 52.7%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 2.7% 1.0%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 6.8% 6.5%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 4.8% 1.9%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 1.2% 2.3%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 3.2% 4.6%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 91.8% 96.7%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 94.6% 99.5%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 16.0% 17.6%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 19.7% 11.2%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 1.1% 1.2%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 85.1% 85.7%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 84.1% 93.1%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 2.3% 1.5%

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