Saint Therese at Oxbow Lake

In the surveyor’s words

From the most serious findings on record at Saint Therese at Oxbow Lake, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF578Dec 6, 2024

  Based 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. Findings include: R63's Death in facility tracking record dated [DATE], indicated R63 passed away in the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Dec 6, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Oct 14, 2021

  Based on observation, interview and document review, the facility failed to date mark opened containers of food stored in two kitchen refrigerators and in a two dry goods storage room, and failed to ensure expired food was identified and removed. In addition, failed to clean and maintain an juice machines, ice makers and coffee maker according to manufacturer instructions. This had the potential to affect all 62 current residents who were served food and beverages from the facility kitchen. Findings include: During the initial kitchen observation with certified dietary manager (CDM) on [DATE], at 12:15 p.m. the following was noted: Basement dry storage and cooler: A case of bananas was being stored on a shelf of a wire rack. […]

• No harm, potential for more than minimal, patternF657Feb 26, 2026

  Based 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.Findings include: R5 R5's admission Minimum Data Set (MDS) dated [DATE], identified R5 had severe cognitive impairment and required assistance with all activities of daily living (ADLs). R5's diagnoses included non-traumatic brain dysfunction, Alzheimer's disease, hypertension (high blood pressure), diabetes mellitus (high blood sugar due to impaired insulin regulation), arthritis (joint inflammation causing pain and stiffness), other fractures (history of bone fractures), anxiety disorder (excessive worry or fear), depression (persistent feelings of sadness), metabolic encephalopathy… […]

• No harm, potential for more than minimal, patternF679Feb 26, 2026

  Based 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).Findings include:R6R6's quarterly Minimum Data Set (MDS), dated [DATE], identified R6 had intact cognition. R6's diagnoses included arthritis (joint inflammation causing pain and stiffness), macular degeneration (loss of central vision), overactive bladder (frequent or urgent need to urinate), cervicalgia (neck pain) and sensorineural hearing loss - bilateral (permanent hearing loss in both ears). […]