Oak Creek Rehabilitation Center of Kimberly

In the surveyor’s words

From the most serious findings on record at Oak Creek Rehabilitation Center of Kimberly, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 4, 2024

  Based on policy review, record review, facility investigation review, and staff interview, the facility failed to prevent physical abuse, verbal abuse, and neglect for 1 of 3 residents (Resident #15) reviewed for abuse. This deficient practice placed Resident #15 in immediate jeopardy of serious harm, impairment, or death when the facility did not protect him from physical and verbal abuse and neglect from LPN #1. Findings include: The facility's Abuse policy, undated, stated residents are to be free from abuse, neglect misappropriation of resident property, and exploitation. The policy further stated staff or management accused employees were immediately removed from resident contact and suspended from duty. […]

• Actual harm, isolatedF609Jul 4, 2024

  Based on policy review, record review, facility investigation review, and staff interview, it was determined the facility failed to report an allegation of physical and verbal abuse and neglect to the State Survey Agency. This was true for 1 of 3 residents (Resident #15) reviewed for abuse. This failure resulted in harm to Resident #15 when the allegation of physical and verbal abuse was not acted on in a timely manner, investigated, and measures implemented to protect residents during the investigation. […]

• No harm, potential for more than minimal, patternF584Dec 5, 2025

  Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 33 residents who resided in the facility whose equipment and environment were observed. This deficient practice created the potential for harm if: a) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, undignified, or b) residents were injured due to unsafe areas in the facility. Findings include: The facility's Preventive Maintenance Program policy, revision date December 2025, documented preventive maintenance schedule included daily tasks of: inspecting halls, exits, lighting . […]

• No harm, potential for more than minimal, patternF880Dec 5, 2025

  Based on observation, interviews and record review, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals, replace resident's soiled equipment, and implement water management control and monitoring measures. This was true for the facility and 1 of 3 residents (Resident #7). These failures placed residents at risk for cross-contamination and infection. Findings include: A. The following was observed during resident meal service in the dining room. 1.On 12/1/25 at 12:40 PM, the lunch meal was served to residents in the dining room. No hand hygiene was offered to the residents prior to eating their food. […]

• No harm, potential for more than minimal, isolatedF600Dec 5, 2025

  Based on record review, the State Survey Agency's Long-Term Care Reporting Portal, and staff interviews, it was determined the facility failed to ensure residents' rights were protected to be free from abuse. This was true for 1 of 3 residents (Resident #4) reviewed for abuse. This failure placed all residents at risk of ongoing abuse, potential physical, and psychosocial harm. Findings include: Resident #4 was initially admitted to the facility on [DATE] with readmission on [DATE], with multiple diagnoses including, hemiplegia (paralysis of one side of the body) and depression. A facility reported incident investigation, initiated 4/27/25 at 11:00 AM, documented CNA #3 heard CNA #2 verbally abuse Resident #4. CNA #3 immediately reported the incident to the Charge Nurse. […]