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? |
|---|---|---|---|---|
| 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 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-20 | 2020-03-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-20 | 2020-03-31 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-20 | 2020-03-31 | 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 | 2020-02-20 | 2020-03-31 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-02-20 | 2020-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-21 | 2020-03-31 | N |
