Oak Creek Rehabilitation Center of Kimberly

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 . On 12/1/25 at 12:00 PM, observed during dining room inspection, directly over tables where residents were eating, was 2 fluorescent lights with large cracks and broken light covers with dead insects on the inside of the light covers.On 12/3/25 at 2:50 PM, the administrator and maintenance director verified the lights needed cleaned and fixed and said they would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. On 12/1/25 at 1:20 PM, LPN #1 stated residents are usually offered hand hygiene prior to eating but the facility had run out of the hand wipes and no hand hygiene was provided today. 2. On 12/1/25 at 12:40 PM, observed staff picking up the residents' knife utensil to pry the meal plate of food out of the warmer tray and replace the knife…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. The DON was notified, and CNA #2 was suspended pending an investigation. On 12/4/25 at 12:02 PM, during record review the facility grievances dated 5/28/25 to 9/27/25 revealed no abuse/neglect issues. On 12/4/25 at 12:32 PM, Resident Council…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, policy review, and record review, the facility failed to ensure a copy of the residents' discharge or transfer notices were sent to the Office of the State Long Term Care (LTC) Ombudsman. This was true for 1 of 1 Residents (Resident #2) reviewed for Ombudsman notification. This failed practice had the potential to affect all residents by; 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges. Findings include:Review of the facility's Discharge and Transfer policy, revision date 4/17/2025, documented a copy of the notice [of discharge] is sent to the Office of the State Long-Term Care (LTC) Ombudsman after discharge.Appendix PP states the following:S483.15(c)(3) Notice of Transfer or Discharge and Ombudsman NotificationWhen a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the State Operations Manual - Appendix PP, facility policy, record review, and staff interview, it was determined the facility failed to make a referral to the state mental health authority for a possible new PASRR level II evaluation when residents were diagnosed with a new serious mental disorder. This was true for 1 of 1 resident (Resident #6), whose PASRR records were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed, treated, and monitored appropriately. Findings include:The facility's Resident Assessments PASRR Screening Coordination policy, dated April 2025, documented:- The facility would notify the state designated agency when a resident with a mental disorder experiences a significant change in status.- Refer to the appropriate state designated authority any resident with newly evident or possible serious mental disorder, intellectual disability, or related condition.Resident #6 was initially admitted to the facility on [DATE], with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to follow physician orders of delivering specific medications when residents did not have BM within 72 hours for 2 of 8 residents (#5 and #21) whose records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include:A. Resident #5 was admitted to the facility initially on 5/5/22 with readmission on [DATE], with multiple diagnoses including depression and anxiety.Resident #5's physician orders for bowel care management were documented as: Day 3 no BM: Administer Miralax 17 grams PO in fluid of choice during medication pass as needed for constipation. Start date 7/8/25 Day 4 no BM: if no BM by 4am, give Dulcolax suppository, as needed for constipation. Start date 7/8/25 Day 5 no BM: If no BM by 2 pm, notify provider for additional instruction. Start date 7/8/25 Resident #5 had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure resident received oxygen as prescribed by the provider. This was true for 1 of 3 residents (Resident #7) reviewed for respiratory care. This failure created the potential for respiratory difficulties or impaired breathing. Findings include: Resident #7 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including respiratory failure and depression. Resident #7's medical record included physician orders for oxygen 2 liters per minute via nasal cannula at HS and PRN. Notify provider if O2 sat% < 90%. Order start date of 1/18/25. On 12/1/25 at 10:50 AM, observed Resident #7 sitting in bed with oxygen administered at 4L/min via mask. On 12/1/25 at 10:55 AM, LPN #1 stated she was unsure of Resident #7's ordered oxygen rate but knew resident was to have oxygen on while in bed and at night. On 12/2/25 at 1:10 PM, observed Resident #7 sitting in bed with oxygen at 3L/min via mask. On 12/2/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the State Operations Manual, Appendix PP, staffing schedules, and staff interviews, it was determined the facility failed to a) ensure full-time nurse aides working less than 4 months are enrolled in a State approved nurse aide training and competency evaluation program (NATCEP) and b) ensure full-time nurse aides working in the facility more than 4 months have successfully completed a NATCEP. This was true for 10 of 13 nurse aides whose personnel files were reviewed. This failure had the potential to result in negative outcomes for the 33 residents living in the facility. Findings include:On 12/5/25,13 Nurse Aide (NAs) files were reviewed with the following results:- NA #1 was hired on 1/6/25. Has not successfully completed a NATCEP.- NA #2 was hired on 1/10/25. Has not successfully completed a NATCEP.- NA #3 was hired on 6/18/25. Has not successfully completed a NATCEP.- NA #4 was hired on 9/30/25. Has not enrolled in a NATCEP.- NA #5 was hired on 10/1/25. Has not enrolled in a NATCEP. - NA #6 was hired on 10/13/25. Has not enrolled in a NATCEP. - NA #7 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the State Operations Manual, Appendix PP, observation, and staff interview, it was determined the facility failed to ensure the daily nurse staffing information was accurately posted for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's current staffing levels. Findings include:On 12/3/25, the daily postings of licensed and unlicensed nurse staffing were reviewed between 4/1/25 - 11/30/25. There were no adjustments to the posted staffing when the scheduled hours did not match the actual hours worked.On 12/3/25 at 9:45 AM, the RNC and DON stated the facility does not make adjustments to the daily postings with actual hours worked, they only adjust the time on the daily assignment sheets.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include:On 12/1/25 at 10:45 AM, during the 100 & 200 Hall medication cart audit, observed the narcotic accountability sheets, dated 11/5/25 to 12/1/25, with 2 licensed nurse signatures not documented on 11/25/25 and 11/26/25. On 12/1/25 at 10:47 AM, LPN #3 stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 12/3/25 at 9:40 AM, during the Dining room & 300 Hall medication cart audit, observed the narcotic accountability sheets, dated 11/26/25 to 12/3/25, with 1 licensed nurse signature not documented on 12/2/25. On 12/3/25 at 9:42 AM, LPN #2 stated the two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors when 1 of 2 residents (Resident #6) did not receive her Invega injection (antipsychotic medication) as ordered by the physician. This failure had the potential to cause harm if the resident's psychiatric behaviors increased due to not receiving her medications timely. Findings include:Resident #6 was initially admitted to the facility on [DATE], with multiple diagnoses including epilepsy (a brain disorder causing unprovoked seizures), anxiety disorder, and bipolar disorder (a mental health condition causing extreme mood swings). Schizophrenia was added to her diagnosis on 5/18/15.Resident #6's physician order start date 2/24/24, documented the following: Invega Sustenna Intramuscular Suspension Prefilled Syringe 234 MG/1.5ML (Paliperidone Palmitate) Inject 1 dose intramuscularly one time a day every 28 day(s) for paranoid schizophrenia.On 10/4/25, Resident #6's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and staff interviews it was determined the facility failed to ensure medications were properly stored, not expired, and biologicals were labeled when opened. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy, use of expired biologicals, and the potential for theft and/or diversion. Findings include: The EvenCare ProView users Guide documented the testing solutions should be dated when bottle opened and discarded after 3 months of use or at time of printed expiration date. The State Operations Manual, Appendix PP, updated 8/8/24, Schedule II-V medications must be maintained in separately locked, permanently affixed compartments.A.The following was observed during the medication cart audits. On 12/3/25 at 10:52 AM, the dining room/300 Hall medication cart was audited with LPN #2 present. Observed the following: - one bottle of Vitamin D with an expiration date of 3/20/25- one bottle of Aspirin 81mg containing round yellow tablets and round orange tablets On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the Idaho Food Code, the facility failed to ensure food was appropriately stored, distributed, and labeled. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination, use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The Idaho Food Code, revised February 2021, documented, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. On 12/1/25 at 10:10 AM, during the initial observation of the kitchen, the following was observed with cook #1 present. Reach-in refrigerator: -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to provide a safe, clean and comfortable environment for residents in 2 of 2 shower rooms (200 hall and 300 hall). This failure had the potential to put residents at risk for a diminished quality of life. Findings included:On 12/3/25 at 1:17 PM, observed the shower room on the 200 hall, the following was noted: 10-inch x 5-inch x1.25-inch jagged shaped hole in floor by shower stall with the area of the flooring peeling off the surface of the floor and not cleanable. 4 holes in middle of shower room floor; 3 of the holes measured 2-inch circle, and 1 hole measured 4-inch jagged circular shape with each of the four areas of the flooring peeling off the surface of the floor and not cleanable. The floor had soiled and darkened matter in the gaps and crevices. On 12/3/25 at 1:37 PM, observed the shower room on the 300 hall, the following was noted: The left shower stall was filled with equipment; lift, large bucket, and chair. A 16-inch x7-inch x 2-inch jagged hole in flooring by entry of the left shower stall with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.