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 100
Perc of occupied beds 83
Sprinkler status Yes
Last health survey date 04/27/2012
Fire survey date: 05/17/2012
Ratings Summary: THE OAKS OF BREVARD
Overall rating 2
2
Nursing Home Staffing 4
4
Registered Nurses only 4
4
Health Inspections 1
1
Quality Measures 5
5
Nursing Home Staffing Info: THE OAKS OF BREVARD
National AverageTHE OAKS OF BREVARD
Overall staff rating Not Available. 4
4
Registered Nurses only rating Not Available 4
4
Total Number of Residents 88.1 100.00
Total Number of Licensed Nurse Staff Hours per Resident per Day 29.8 hours 1.67 hours
Registered Nurses Hours per Residents per Day 29.0 hours .99 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 29.0 hours .68 hours
Certified Nursing Assistants Hours per Residents per Day 29.0 hours .99 hours
Health Inpections: THE OAKS OF BREVARD
Inspection Results: 04/27/2012
CorrectedCategoryDeficiencySeverity
05/25/2012Administration DeficienciesKeep accurate, complete and organized clinical records on each resident that meet professional standards. D
05/25/2012Administration DeficienciesOperate and provide services according to Federal, State, and local laws and professional standards. B
05/25/2012Pharmacy Service DeficienciesMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. E
05/25/2012Nutrition and Dietary DeficienciesStore, cook, and serve food in a safe and clean way. E
05/25/2012Nutrition and Dietary DeficienciesProvide special eating equipment and utensils for each resident who needs them. D
05/25/2012Nutrition and Dietary DeficienciesProvide food in a way that meets a resident's needs. D
05/25/2012Quality Care DeficienciesDevelop policies and procedures for influenza and pneumococcal immunizations. D
05/25/2012Pharmacy Service DeficienciesEnsure 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. D
05/25/2012Environmental DeficienciesEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. D
05/25/2012Quality Care DeficienciesAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene. D
05/25/2012Quality Care DeficienciesMake sure that residents receive treatments/services to maintain or improve their ability to care for themselves. D
05/25/2012Quality Care DeficienciesEnsure services provided by the nursing facility meet professional standards of quality. D
05/25/2012Resident Assessment DeficienciesDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D
05/25/2012Resident Rights DeficienciesProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. D
05/25/2012Resident Rights DeficienciesListen to the resident groups and act on their complaints and suggestions that affect resident care and life. E
05/25/2012Environmental DeficienciesProvide housekeeping and maintenance services. D
Inspection Results: 06/23/2011
CorrectedCategoryDeficiencySeverity
07/21/2011Environmental DeficienciesHave a program that investigates, controls and keeps infection from spreading. D
07/21/2011Pharmacy Service DeficienciesMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. D
07/21/2011Nutrition and Dietary DeficienciesStore, cook, and serve food in a safe and clean way. E
07/21/2011Quality Care DeficienciesProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. D
07/21/2011Environmental DeficienciesEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. D
07/21/2011Mistreatment Deficiencies1) 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. D
07/21/2011Quality Care DeficienciesAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene. D
07/21/2011Quality Care DeficienciesEnsure services provided by the nursing facility meet professional standards of quality. D
07/21/2011Mistreatment DeficienciesDevelop 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. D
07/21/2011Quality Care DeficienciesEnsure 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. D
Inspection Results: 07/15/2010
CorrectedCategoryDeficiencySeverity
08/13/2010Quality Care DeficienciesAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene. D

Fire Safety Inpections: THE OAKS OF BREVARD
Inspection Results: 05/17/2012
CorrectedCategoryDeficiencySeverity
07/01/2012Automatic Sprinkler Systems DeficienciesAn approved automatic sprinkler system connected to the fire alarm system. E
Inspection Results: 07/19/2011
CorrectedCategoryDeficiencySeverity
09/02/2011Automatic Sprinkler Systems DeficienciesAutomatic sprinkler systems that have been maintained in working order. D
09/02/2011Electrical DeficienciesWeekly inspections and monthly testing of generators. D
Inspection Results: 08/11/2010
CorrectedCategoryDeficiencySeverity
09/23/2010Exit and Exit Access DeficienciesAt least two remote exits on each floor or fire section of the building. D
09/23/2010Smoke Compartmentation and Control DeficienciesWalls that prevent smoke from passing through and would resist fire for at least one hour. D

Resident Complaints: THE OAKS OF BREVARD
Date Complaint Substantiated: 04/27/2012
CorrectedCategoryDeficiencySeverity
05/25/2012Administration DeficienciesKeep accurate D
05/25/2012Environmental DeficienciesEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. D
05/25/2012Quality Care DeficienciesAssist those residents who need help with eating/drinking D
05/25/2012Quality Care DeficienciesEnsure services provided by the nursing facility meet professional standards of quality. D
05/25/2012Environmental DeficienciesProvide housekeeping and maintenance services. D
05/25/2012Resident Rights DeficienciesProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. D
05/25/2012Resident Rights DeficienciesListen to the resident groups and act on their complaints and suggestions that affect resident care and life. E
Date Complaint Substantiated: 12/19/2011
CorrectedCategoryDeficiencySeverity
01/16/2012Quality Care DeficienciesProvide medically-related social services to help each resident achieve the highest possible quality of life. D
Date Complaint Substantiated: 07/19/2011
CorrectedCategoryDeficiencySeverity
08/05/2011Quality Care DeficienciesEnsure services provided by the nursing facility meet professional standards of quality. D
08/05/2011Environmental DeficienciesEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. D
Date Complaint Substantiated: 06/23/2011
CorrectedCategoryDeficiencySeverity
07/21/2011Environmental DeficienciesHave a program that investigates D
Date Complaint Substantiated: 07/15/2010
CorrectedCategoryDeficiencySeverity
07/15/2010Administration DeficienciesEnsure the activities program is directed by a qualified professional. C

Quality Measures: THE OAKS OF BREVARD
Quality MeasuresNational AverageTHE OAKS OF BREVARD
Overall quality rating Not Available 5
5
Long-Stay Residents
Percent of long-stay residents experiencing one or more falls with major injury. 12% 1.6000000000000001%
Percent of long-stay residents who have depressive symptoms. 16% 7.5%
Percent of long-stay residents who received an antipsychotic medication. 31% 26.399999999999999%
Percent of long-stay residents who were physically restrained. 11% 1.2%
Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine. 97% 92.700000000000003%
Percent of long-stay residents who have/had a catheter inserted and left in their bladder. 13% 5.2999999999999998%
Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine. 99% 99.599999999999994%
Percent of long-stay residents who self-report moderate to severe pain. 22% 0.5%
Percent of long-stay high-risk residents with pressure ulcers. 19% 2%
Percent of long-stay residents whose need for help with daily activities has increased. 27% 12.9%
Percent of long-stay residents who lose too much weight. 16% 4.4000000000000004%
Percent of long-stay low-risk residents who lose control of their bowels or bladder 62% 46.5%
Percent of long-stay residents with a urinary tract infection. 16% 4.4000000000000004%
Short-Stay Residents
Percent of short-stay residents with Pressure ulcers that are new or worsened. 11% 0.29999999999999999%
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine. 87% 96.400000000000006%
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine. 92% 98.700000000000003%
Percent of short-stay residents who newly received an antipsychotic medication. 27% 5.5999999999999996%
Percent of short-stay residents who self-report moderate to severe pain. 36% 7.7000000000000002%
Severity Codes Explanation. Note: The higher the letter, the higher the severity.
AIsolated /Potential for minimal harm
BPattern /Potential for minimal harm
CWidespread /Potential for minimal harm
DIsolated /Minimal harm or potential for actual harm
EPattern /Minimal harm or potential for actual harm
FWidespread /Minimal harm or potential for actual harm
GIsolated /Actual harm
HPattern /Actual harm
IWidespread /Actual harm
JIsolated /Immediate jeopardy to resident health or safety
KPattern /Immediate jeopardy to resident health or safety
LWidespread /Immediate jeopardy to resident health or safety

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