Medical Suites at Oak Creek (The)

In the surveyor’s words

From the most serious findings on record at Medical Suites at Oak Creek (The), in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Aug 15, 2022

  Based on observation, interview and record review the facility did not ensure its infection control program was implemented regarding a COVID-19 outbreak. On [DATE] R3, who resides on the 200 unit and who has a history of pneumonia, acute and chronic [CONDITION(S)], [CONDITION(S)], history of tuberclosis and is on oxygen, became more congested and developed a cough. Nursing suspected he might have COVID-19 but did not test him and did not implement isolation precautions. Two days later, on [DATE] using a Rapid test, R3 tested positive for COVID-19. The facility did not implement their outbreak procedures/testing on [DATE], waiting to conduct staff and resident testing on [DATE]. […]

• Immediate jeopardy, patternF684May 7, 2026

  Based on interview and record review, the facility failed to ensure 5 (R14, R5, R31, R12, and R8) of 5 sampled residents received care and treatment in accordance with assessments and professional standards of practice (including N6, Nurse Practice Act) to ensure their highest practicable physical, mental, and psychosocial well-being. Facility staff did not assess changes in condition, did not ensure orders for labs and treatments were promptly implemented, and did not communicate condition changes to appropriate personnel as necessary to ensure consistency and continuity of care across all disciplines. * R14's Annual Minimum Data Set, dated [DATE] assessed R14 as having declines in her incontinence and mobility during the look back time frame. […]

• Immediate jeopardy, patternF578Apr 17, 2024

  Based upon interview and record review, the facility did not ensure the rights of 8 (R1, R15, R16, R17, R18, R19, R20, and R21) of 15 residents to formulate their advanced directive preferences to receive cardiopulmonary resuscitation (CPR) (full code) or do not resuscitate (DNR) if found pulseless and not breathing. *R1 was admitted to the facility on [DATE]. During the admission process, R1 was given a facility Code Status Election form to complete. This document has both Resuscitation and Do Not Resuscitate checked. On the form, the box next to Resuscitation has an X in it and is circled and the box next to No Resuscitation has an X in it and the words are boxed off (bracketed). The document is signed by R1 but does not clearly indicate R1's wishes at the time of signature. […]

• Immediate jeopardy, isolatedF686May 7, 2026

  Based on record review, observation and interview, the facility failed to ensure 3 (R14, R15 and R32) of 3 sampled residents with pressure injuries received care and treatment based upon standards of practice to promote healing, prevent infection, and prevent new pressure injuries from developing. * R14 was assessed to be at risk for pressure injuries and was noted to have a pressure injury that was healed on 12/1/25. 12/3/25 was the assessment reference date for R14's annual minimum data set (MDS). This MDS assessed R14 as requiring greater assistance for turning and repositioning and decline in incontinence of bladder for R14. […]

• Immediate jeopardy, isolatedF689May 7, 2026

  Based on observation, interview, and record review, the facility did not ensure 3 residents (R) of 4 residents reviewed were provided with adequate supervision and assistance to prevent accidents (R11, R5, and R13.) *R11 had an unwitnessed fall, without injury, on 2/13/2026. The facility did not implement immediate fall interventions, complete a fall investigation, determine a root cause, or review/revise the fall care plan to prevent further falls. R11 experienced another fall on 2/14/2026, which resulted in a laceration to R11's right eye and a Traumatic Brain Injury (TBI) requiring admission to a Neurology Intensive Care Unit. *R5 is documented as being dependent on staff for all cares. On 4/5/26, Certified Nursing Assistant (CNA)-X was performing cares alone with R5 in bed. […]