West Oaks was cited by the Centers for Medicare and Medicaid Services (CMS) for multiple deficiencies during an unannounced complaint investigation survey, including failing to timely address a patient’s grievances. CMS found that one patient had submitted a complaint about being dissatisfied with her physician, being kept in the hospital for too long, and not getting her prescriptions filled, but her calls to the facility’s patient advocate were not returned and a resolution to the grievance was not provided. West Oaks was also cited for failing to administer medications according to accepted standards of practice. The facility administered medications to two patients who had documented allergies to the drugs. CMS also determined West Oaks failed to ensure that the facility’s infection control officer implemented policies to control infections and communicable diseases in four of five adult care units.For example, CMS surveyors found that black “mold-looking” substances were present in the showers, three direct care staff members were allowed to work without being tested for Tuberculosis, and laundry was left uncovered while being transported between rooms. As a result of these citations, the facility had to submit a plan of correction to address its cited deficiencies and deficient practices, which included staff re-training.