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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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