Oak Creek Terrace Inc

In the surveyor’s words

From the most serious findings on record at Oak Creek Terrace Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880May 15, 2025

  Based on observation, medical record review, and staff interviews, the facility failed to ensure infection control practices were followed during a dressing change for a pressure ulcer. This affected one (#29) of the two residents reviewed for pressure ulcers during the annual survey. The facility identified two residents (#27 and #29) with pressure ulcers. The facility also failed to ensure their Water Management Plan (WMP) was followed. This had the potential to affect 62 residents who resided in the facility. The facility census was 62. Findings included: 1) Review of the medical record for Resident #29 revealed an admission date of 09/15/22. […]

• No harm, potential for more than minimal, patternF880Sep 29, 2025

  Based on observation, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care for a resident who was positive for COVID-19, and failed to complete proper hand hygiene prior to exiting the room. This affected one (#24) of five residents reviewed for infection control. The facility identified there were five residents who were positive for COVID-19 (and resided on the dementia care unit) during the survey. This had the potential to affect 10 residents who resided on the dementia care unit who were not positive for COVID-19. Findings include: Medical record review for Resident #55 revealed an admission of 02/14/22. […]

• No harm, potential for more than minimal, patternF812May 15, 2025

  Based on observations, staff interviews and policy review, the facility failed to ensure food and utensils were stored in a safe and sanitary manner. This had the potential to affect 61 out of the 62 residents as the facility identified one resident (#41) with a diet of nothing by mouth (NPO) and received no food from the kitchen. The facility census was 62. Findings include: Observation of the kitchen on 05/14/25 at 12:11 P.M. with Dietary Manager (DM)#06, revealed frozen bags of pot roast were being stored in water in the preparation (prep) sink. Interview at the same time with DM #06, verified they were thawing the pot roast and that cold water should be running while food is thawing in the sink. Continued observation of the kitchen on 05/14/25 at 12:13 P.M. […]

• No harm, potential for more than minimal, patternF656Apr 29, 2022

  Based on record review, staff interview, and policy review, the facility failed to ensure comprehensive care plans were completed in the areas of activities, activities of daily living, dehydration, and pain . This affected six (#23, #05, #43, #467, #469, and #57) of 18 residents reviewed for comprehensive care plans. The facility census was 62. Findings included: 1. Medical record review for Resident #23 revealed an admitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was rarely or never understood. His functional status was extensive assistance for bed mobility and toilet use. He was total dependence for transfers and eating. He was always incontinent for bladder and bowel. […]

• No harm, potential for more than minimal, patternF805Apr 29, 2022

  Based on observation and interview, the facility failed to use a recipe to accurately make pureed texture food. This affected all six Residents (#07, #18, #23, #29, #42, #469) with orders for pureed diets. The facility census was 62. Findings include Interview and observation on 04/27/22 at 10:35 A.M. with Dietary Staff #13 revealed residents were having pot roast with the menu giving guidance of 3-ounce (oz) servings. She revealed six residents have orders for pureed meals and she placed six - 3 oz servings of meat along with six - 3 oz servings of broth in the blender. Dietary #13 also revealed she adds bread to each item in the meal (meats and vegetables) and added three slices of bread to the blender. She turned on the blender to begin mixing. […]