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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?
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-07-15 2024-10-01 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-07-15 2024-10-01 Y
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-07-08 2024-09-11 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 2024-07-15 2024-08-12 N
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 2024-07-15 2024-08-12 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-07-15 2024-08-12 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 2024-07-15 2024-08-12 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 2024-07-15 2024-08-12 N
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 2024-07-15 2024-08-12 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-07-15 2024-08-12 N
Dispose of garbage and refuse properly. Health 2024-07-15 2024-08-12 N
Provide and implement an infection prevention and control program. Health 2024-07-15 2024-08-12 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2024-07-15 2024-08-12 N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2024-07-15 2024-08-12 N
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
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2024-07-08 2024-08-12 N
Have properly located and lighted "Exit" signs. Fire Safety 2024-07-08 2024-08-12 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2024-07-08 2024-08-12 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-07-08 2024-08-12 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-07-08 2024-08-12 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-07-08 2024-08-12 N
Provide a written emergency evacuation plan. Fire Safety 2024-07-08 2024-08-12 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-07-08 2024-08-12 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-07-08 2024-08-12 N
Have restrictions on the use of portable space heaters. Fire Safety 2024-07-08 2024-08-12 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-07-08 2024-08-12 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-07-08 2024-08-12 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2024-07-08 2024-08-08 N
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

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