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Deficiency Records for Saint Therese at Oxbow Lake
A list of the most recent deficiencies for Saint Therese at Oxbow Lake. 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 Saint Therese at Oxbow Lake. 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-08-07 | 2024-09-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-07 | 2024-09-11 | Y |
| 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 | 2024-03-07 | 2024-05-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-07 | 2024-05-03 | 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 | 2024-03-07 | 2024-05-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-07 | 2024-05-03 | 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 | 2024-03-07 | 2024-05-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-03-07 | 2024-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-05 | 2024-05-03 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2024-03-05 | 2024-05-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-03-05 | 2024-05-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-05 | 2024-04-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-03-05 | 2024-03-27 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-04-19 | 2023-05-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-18 | 2023-05-26 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2023-04-18 | 2023-05-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-19 | 2023-05-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-18 | 2023-04-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-10-14 | 2022-01-06 | 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 | 2021-10-14 | 2022-01-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-14 | 2022-01-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-14 | 2022-01-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-14 | 2022-01-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-10-14 | 2022-01-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-14 | 2022-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-13 | 2021-12-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-13 | 2021-10-19 | N |
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