Saint Therese at Oxbow Lake

Inspectors wroteBased on observation, interview and record review the facility failed to ensure care plans were revised for 6 of 14 residents (R5, R8, R10, R40, R47 and R7) whose care plans were reviewed for accuracy.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received an ongoing program of activities designed to meet their assessed needs, interests, and abilities in accordance with their comprehensive care plans for 4 of 5 residents reviewed for activities (R6, R10, R13, and R42).

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident was treated with dignity and respect by maintaining privacy of a urinary catheter drainage bag, resulting in the visible exposure of urine to others passing by for 1 of 1 resident observed (R10).

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were provided the opportunity to participate in the planning of their care through timely care conferences for 2 of 7 residents reviewed for care planning (R8 and R19).

Inspectors wroteBased on interview and document review the facility failed to ensure discharge against medical advice (AMA) was documented for 1 of 1 residents (R76) reviewed for discharge. R76's entry minimum data set (MDS) dated [DATE], indicated R76 admitted to the facility on [DATE]. R76 admitted from a hospital stay. R76's discharge MDS dated [DATE], indicated R76 had an unplanned discharge. R76 had diagnoses that included lumbar vertebra compression fracture, depression, hallucinations, and peripheral vascular disease. Progress note dated 12/18/25, at 2:10 p.m. indicated R76 admitted to facility following hospitalization. Progress note dated 12/18/25, at 7:06 p.m. indicated R76 had gotten agitated and physically aggressive towards staff. Staff attempted to redirect but unsuccessful. Resident was noted attempting unsafe self-transfers. [...]

Inspectors wroteBased on interview and document review the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 1 of 2 residents (R76) reviewed for discharge. R76's entry minimum data set (MDS) dated [DATE], indicated R76 admitted to the facility on [DATE], R76 admitted from a hospital stay. R76's discharge MDS dated [DATE], indicated R76 had an unplanned discharge. R76 had diagnoses that included lumbar vertebra compression fracture, depression, hallucinations, and peripheral vascular disease. Review of the December 2025 and January 2026 Ombudsman notifications sent by the facility failed to indicate Ombudsman office was notified R76 had discharged from the facility. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's comprehensive care plan was individualized and resident-specific for 1 of 1 resident (R19) reviewed for behavioral care planning.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure residents who were dependent on others for activities of daily living (ADLs) received the services needed. This affected 1 of 3 residents (R65) observed for partial bathing and nail care and 1 of 3 residents (R47) observed for facial shaving.

Inspectors wroteBased on observation, record review and interview the facility failed to identify, assess and monitor a new skin concern for 1 of 1 resident (R47) observed for quality of care. Additionally the facility failed to ensure care and services were provided in accordance with professional standards of practice to prevent avoidable harm when assisting a resident with mobility for 1 of 1 resident (R19) observed for wheelchair mobility.

Inspectors wroteBased on record review and interview, the facility failed to ensure interventions identified in the comprehensive care plan were implemented to prevent the recurrence of pressure ulcers for 1 of 3 residents reviewed for pressure ulcer prevention (R6).

Inspectors wroteBased on observation, record review and interview the facility failed to following therapy recommended ambulation program for 1 of 1 resident (R40) reviewed with scheduled ambulation assistance.

Inspectors wroteBased on document review, interview and observation, the facility failed to ensure a root cause analysis was completed after a fall to determine interventions to prevent falls, and failed to continue to assess for changes after a head injury per policy, for 1 of 3 (R5) residents reviewed for falls.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure appropriate infection control practices were followed for 1 of 1 resident (R25) reviewed who was diagnosed with COVID and received an aerosol breathing treatment.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of the 5 residents (R5) reviewed for immunizations was offered and/or provided the pneumococcal vaccination series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2025, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received no prior pneumococcal vaccine should receive PCV20 or PCV21, those who had received the complete series (i.e., PPSV23 and PCV13; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was provided to each resident residing in the facility and displayed for residents, visitors and staff to review. This had the potential to affect all 53 residents currently residing in the facility as well as all staff and visitors.

Inspectors wroteBased on observation and interview, the facility failed to ensure facility survey results were posted in an accessible location for residents, staff and visitors. This had the potential to affect all 53 residents residing in the facility as well as staff and visitors.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident-specific resuscitation wishes, based on a signed Physician Orders for Life Sustaining Treatment (POLST, a medical order indicating treatments a person would like to receive in case of serious illness and/or cardiac arrest), were accurately reflected throughout the electronic medical record (EMR) for 1 of 2 residents (R63) reviewed for advanced directives. Additionally, the facility failed to have and follow policies and procedures for implementing advance directives. This had the ability to affect all 60 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to cool meat at temperatures and timeframes to reduce bacterial growth, which had potential to affect all residents, staff, and visitors who consumed food from the main kitchen. In addition, the facility failed to serve food in a manner to prevent contamination and failed to ensure the second-floor ice and water dispensing machine was clean and free of excess mineral build up, which had potential to affect all residents, staff, and visitors who consumed food and ice and/or water from the second-floor kitchen area. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medications assessment was completed to allow resident to safely administer their own medications for 1 of 1 resident (R9) observed with medications at bedside.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident call light was within reach for 1 of 4 residents (R115) reviewed for call lights within reach.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow contact precautions and perform evidence-based hand hygiene to reduce the spread of clostridium difficile (C. diff, a highly contagious bacterium that causes diarrhea) for 1 of 1 residents (R164) reviewed for transmission-based precautions (TBP). In addition, the facility failed to ensure proper hand hygiene and glove use was utilized for 1 of 2 residents (R14) observed during personal cares. Furthermore, the facility failed to ensure infection control policies were reviewed on an annual basis. This had the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure 3 of 5 residents (R9, R20, R30) were offered and/or provided updated vaccinations for pneumococcal disease in accordance with the Centers for Disease Control (CDC) vaccination recommendations. Additionally, the facility failed to ensure 1 of 5 residents (R30) was offered and/or provided updated vaccinations for influenza disease.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents with food allergies were not served allergens for 1 out of 3 residents (R1) reviewed for accuracy of diets.

Inspectors wroteBased on interview and document review, the facility failed to develop a person-centered baseline care plan upon admission, and failed to assess, revise and implement new fall interventions for 3 of 3 residents (R1, R2, and R3) who admitted with fall risks and sustained falls after admission.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess fall risk and implement individualized fall interventions to reduce the risk of falls for 3 of 3 residents (R1, R2, R3) reviewed for accidents.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident specific advanced directive orders were accurately reflected throughout the medical record for 1 of 4 residents (R3) reviewed for advanced directives.

Inspectors wroteBased on observation, interview and document review the facility failed to implement current fall interventions and develop immediate fall interventions to decrease the risk of additional falls for 1 of 1 resident (R5) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement interventions to reduce infection for 1 of 1 resident (R47) reviewed for urinary catheter.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure pain was managed consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 4 residents (R2, R12, R106) reviewed for pain management. Furthermore, the facility failed to implement non-pharmacological interventions for pain management for 2 of 2 residents (R12 ,R106). R12 R12's admission Minimum Data Set (MDS) dated [DATE], identified R12 had moderately impaired cognition and required partial/moderate assistance for most activities of daily living (ADLs) such as dressing, bed mobility, and transferring. R12's MDS indicated R12 had arthritis (condition with swelling and tenderness of one or more joints) and osteoporosis (condition when bone strength weakens). [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure appropriate side effect monitoring was completed related to psychotropic medication use for 1 of 5 residents (R5) and failed to ensure as-needed (PRN) psychotropic medication use was limited to 14 days or had documented rationale for extended use beyond 14 days for 1 of 5 residents (R20) reviewed for unnecessary medications.