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Deficiency Records for The Medical Suites at Oak Creek
A list of the most recent deficiencies for The Medical Suites at Oak Creek. 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 The Medical Suites at Oak Creek. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-15 | 2024-08-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-15 | 2024-08-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-15 | 2024-08-12 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-15 | 2024-08-12 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-07-15 | 2024-08-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-15 | 2024-08-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-15 | 2024-08-12 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-04-17 | 2024-05-02 | 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 | 2024-04-17 | 2024-05-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-04-17 | 2024-05-02 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-04-17 | 2024-05-02 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-04-17 | 2024-05-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-17 | 2024-05-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-17 | 2024-05-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-17 | 2024-05-02 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-04-17 | 2024-05-02 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-04-17 | 2024-05-02 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-04-17 | 2024-05-02 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-19 | 2023-10-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-19 | 2023-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-19 | 2023-09-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-19 | 2023-09-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-19 | 2023-09-20 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-19 | 2023-08-29 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-27 | 2023-08-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-27 | 2023-08-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-07-27 | 2023-08-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-27 | 2023-08-22 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-07-27 | 2023-08-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-27 | 2023-08-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-27 | 2023-08-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-27 | 2023-08-22 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-07-27 | 2023-08-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-27 | 2023-08-22 | 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 | 2023-07-27 | 2023-08-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-07-27 | 2023-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-27 | 2023-08-22 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-07-27 | 2023-08-22 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-07-27 | 2023-08-22 | N |
| Provide training in compliance and ethics. | Health | 2023-07-27 | 2023-08-22 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-07-27 | 2023-08-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-27 | 2023-08-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-27 | 2023-08-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-27 | 2023-08-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-27 | 2023-08-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-19 | 2023-08-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-19 | 2023-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-19 | 2023-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-19 | 2023-08-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-19 | 2023-08-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-19 | 2023-08-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-19 | 2023-08-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-10 | 2023-04-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-23 | 2023-04-14 | Y |
| 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 | 2023-03-23 | 2023-04-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-23 | 2023-04-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-23 | 2023-04-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-23 | 2023-04-14 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-23 | 2023-04-14 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-03-23 | 2023-04-14 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-03-23 | 2023-04-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-23 | 2023-04-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-23 | 2023-04-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-23 | 2023-04-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-23 | 2023-04-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-23 | 2023-04-14 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-03-23 | 2023-04-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-23 | 2023-04-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-23 | 2023-04-14 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-03-23 | 2023-04-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-14 | 2023-04-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-14 | 2023-04-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-14 | 2023-04-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-14 | 2023-04-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-14 | 2023-04-14 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-12-14 | 2023-04-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-14 | 2023-04-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-14 | 2023-04-14 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-12-14 | 2023-03-23 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-12-14 | 2023-03-23 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-14 | 2023-03-23 | Y |
| 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 | 2022-12-14 | 2023-03-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-14 | 2023-03-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-14 | 2023-03-23 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-12-14 | 2023-03-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-21 | 2022-09-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-21 | 2022-09-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-15 | 2022-09-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-21 | 2022-09-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-15 | 2022-09-22 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-08-15 | 2022-09-21 | Y |
| 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 | 2022-08-15 | 2022-09-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-15 | 2022-09-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-15 | 2022-09-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-15 | 2022-09-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-15 | 2022-09-21 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-08-15 | 2022-09-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-15 | 2022-09-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-15 | 2022-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-15 | 2022-09-21 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-03-30 | 2022-04-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-03-30 | 2022-04-25 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-03-30 | 2022-04-25 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-03-30 | 2022-04-25 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-30 | 2022-04-25 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-03-30 | 2022-04-25 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-30 | 2022-04-25 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-03-30 | 2022-04-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-30 | 2022-04-25 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-03-30 | 2022-04-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-30 | 2022-04-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-30 | 2022-04-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-30 | 2022-04-25 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-30 | 2022-04-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-30 | 2022-04-25 | Y |
| 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 | 2022-03-30 | 2022-04-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-30 | 2022-04-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-30 | 2022-04-25 | Y |
| Dispose of garbage and refuse properly. | Health | 2022-03-30 | 2022-04-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-30 | 2022-04-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-30 | 2022-04-25 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2022-03-29 | 2022-04-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-03-29 | 2022-04-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-29 | 2022-04-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-29 | 2022-04-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-29 | 2022-04-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-29 | 2022-04-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-29 | 2022-04-25 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-03-29 | 2022-04-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-29 | 2022-04-25 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-03-29 | 2022-04-25 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-02-16 | 2022-03-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-16 | 2022-03-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-16 | 2022-03-11 | Y |
| 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 | 2022-02-16 | 2022-03-11 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-16 | 2022-03-11 | Y |
| Post nurse staffing information every day. | Health | 2022-02-16 | 2022-03-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-16 | 2022-03-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-27 | 2022-02-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-27 | 2022-02-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-27 | 2022-02-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-27 | 2022-02-25 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-01-27 | 2022-02-25 | Y |
| 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 | 2022-01-27 | 2022-02-25 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-12-15 | 2022-01-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-15 | 2022-01-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-15 | 2022-01-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-15 | 2022-01-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-15 | 2022-01-04 | Y |
| 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 | 2021-12-15 | 2022-01-04 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-15 | 2022-01-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-28 | 2021-11-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-28 | 2021-11-17 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-28 | 2021-11-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-28 | 2021-11-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-13 | 2021-11-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-15 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-15 | Not Fixed | Y |
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