Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Creek Rehabilitation Center Of Kimberly during CMS and state inspections, most recent first.
Deficient Dining Room Lighting Maintenance: The facility failed to maintain a clean, safe, homelike environment for all 33 residents observed. During a dining room inspection, two fluorescent lights directly over resident tables were found with large cracks, broken light covers, and dead insects inside the covers, despite the facility’s PM policy calling for daily inspection of lighting. The administrator and maintenance director later verified the lights needed to be cleaned and fixed.
Infection control practices were not followed when residents were not offered hand hygiene before meals, an LPN used a resident’s knife utensil to remove a meal plate from a warmer tray, and a resident’s oxygen tubing and mask were picked up from the floor and placed back on the resident’s face. The facility also lacked an active water management program, had not updated the Water Management Plan, and could not provide weekly control and monitoring logs.
The facility failed to ensure a resident with hemiplegia and depression was free from abuse when a CNA was heard verbally abusing the resident and the incident was reported to the Charge Nurse and DON. Record review showed limited abuse or neglect concerns in grievances and Resident Council Minutes, with one abuse concern noted in council minutes and no other documented issues.
Failure to Send Discharge Notice to Ombudsman: The facility did not ensure a copy of a resident's discharge notice was sent to the State LTC Ombudsman. The resident had a planned discharge to home with HHS and continued PT/OT, but the record lacked documentation that the Ombudsman was notified at the same time the discharge notice was provided to the resident and representative.
A resident with a history of bipolar disorder, epilepsy, and prior PASRR Level II findings later had schizophrenia/paranoid schizophrenia documented in the record, including a care plan for psychoactive meds. The facility did not notify the state mental health authority to request an updated PASRR Level II evaluation for the new serious mental disorder, and the resident’s record did not show a Level II that included paranoid schizophrenia.
Failure to Follow Bowel Management Orders: Two residents had prolonged periods without documented BMs, and the record did not show that ordered bowel meds such as Miralax and Dulcolax were given or that the provider was notified as ordered. One resident had depression and anxiety, and the other had hemiplegia and respiratory failure. The DON stated the nurse had not documented the bowel medication interventions on the MAR as ordered.
A resident with respiratory failure and depression had an order for O2 at 2 L/min via NC at HS and PRN, with instructions to notify the provider if O2 sat was below 90%. Staff observed the resident receiving O2 at 4 L/min via mask and later at 3 L/min via mask, and an LPN and CNA were unsure of the ordered rate. The RNC stated the resident should have been on 2 L/min via NC as ordered and had not been.
Nurse aide training and competency deficiencies were identified when personnel file review showed that several aides who had worked more than 4 months had not successfully completed a NATCEP, and several aides who had worked less than 4 months had not enrolled in a NATCEP. An RNC confirmed that the aides had either not completed the course or had not yet enrolled.
A facility failed to ensure daily nurse staffing information was accurately posted for each shift. Review of the licensed and unlicensed nurse staffing postings showed no adjustments when scheduled hours did not match actual hours worked, and the RNC and DON stated the facility only adjusted the time on the daily assignment sheets.
Controlled medications were not properly tracked on 2 of 2 medication carts reviewed. Narcotic accountability sheets were missing required nurse signatures on multiple occasions, and an LPN and the DON stated that two nurses should have signed the record when accepting or releasing the medication cart.
Missed and Delayed Antipsychotic Injection: A resident with epilepsy, anxiety, bipolar disorder, and schizophrenia did not receive ordered Invega Sustenna injections on time. Staff documented the medication as unavailable, pharmacy delays, and a missing refill, and one dose was given late while another administration was documented in notes but not on the MAR. The DON and RNC stated the nurse should have documented the injection on the MAR and that the physician was not notified until later.
Improper medication, biological, and controlled drug storage was observed in the facility. An expired bottle of Vitamin D was found in a med cart, two bottles of aspirin had been combined into one container, glucose test solutions were left without an opened date and were later dated after the issue was raised, and testing logs showed the solutions were used for weekly glucometer checks over several months. Two bottles of lorazepam concentrated solution were also stored in a removable metal box in the med refrigerator instead of an affixed locked compartment.
Food items in the kitchen were found uncovered, undated, improperly labeled, or past expiration/use-by dates, including cheeses, buns, turkey, egg salad sandwiches, pureed corn, potato salad, yogurt, and freezer corn. The dish machine log was also filled out in advance. In a resident refrigerator, expired pudding cups were present along with dark brown dried material and spills, and an LPN stated the items should have been discarded and the refrigerator cleaned.
Unsafe and Unclean Shower Rooms: Surveyors observed unsafe and unclean conditions in 2 shower rooms, including jagged holes in the flooring with peeling, non-cleanable surfaces and dark matter in the gaps. In one shower room, equipment was stored in the shower stall, the drain contained stool-looking material, the jetted tub was not functioning with a side panel removed, and a salon chair and workstation were placed in the room. The Maintenance Supervisor and DON acknowledged the rooms needed repairs and cleaning.
A resident with severe cognitive impairment and a history of traumatic brain injury was subjected to physical and verbal abuse by an LPN, who improperly used a gait belt and left the resident unattended on the floor. The facility's investigation was inadequate, failing to substantiate the abuse despite witness statements and evidence. The incident was reported late, and the facility's response was delayed, placing the resident in immediate jeopardy.
A facility failed to report an allegation of abuse and neglect involving a cognitively impaired resident in a timely manner. An LPN was rough with the resident, causing him to hit his head and leaving him on the floor for 45 minutes. The incident was reported to HR the next day, contrary to the facility's policy requiring immediate reporting.
Deficient Dining Room Lighting Maintenance
Penalty
Summary
The facility failed to ensure residents were provided with a clean, safe, homelike environment for all 33 residents whose equipment and environment were observed. The facility's Preventive Maintenance Program policy, revised December 2025, included daily tasks for inspecting halls, exits, and lighting, but during a dining room observation on 12/1/25 at 12:00 PM, two fluorescent lights directly over resident dining tables were found with large cracks and broken light covers, with dead insects visible inside the covers. On 12/3/25 at 2:50 PM, the administrator and maintenance director verified that the lights needed to be cleaned and fixed.
Infection Control and Water Management Failures
Penalty
Summary
The facility failed to ensure adherence to infection control and prevention practices when residents were not offered hand hygiene before meals, a resident’s meal plate was handled with the resident’s own knife utensil to remove it from a warmer tray, and a resident’s soiled oxygen tubing and mask were picked up from the floor and placed back on the resident’s face. During lunch meal service in the dining room, no hand hygiene was offered to residents before eating, and an LPN stated the facility had run out of hand wipes and hand hygiene was not provided that day. Staff were also observed using a resident’s knife to pry a meal plate out of the warmer tray and then returning the knife to the table for the resident to use during the meal. In Resident #7’s room, the resident’s oxygen tubing and mask were observed on the floor next to the bed. An LPN picked up the oxygen mask from the floor and placed it on the resident’s face. The DON later stated the oxygen tubing and mask should have been discarded and replaced and had not been. During the infection control interview and record review, the Maintenance Supervisor stated the facility did not have an active water management program in place and the Water Management Plan had not been updated. The facility could not provide the requested weekly logs for the control and monitoring measures referenced in the document, and the RNC stated the Water Management Plan should have been updated and had not been.
Failure to Protect Resident From Verbal Abuse
Penalty
Summary
The facility failed to ensure residents’ rights were protected to be free from abuse. This deficiency involved Resident #4, who was admitted with multiple diagnoses including hemiplegia and depression. A facility-reported incident investigation documented that CNA #3 heard CNA #2 verbally abuse Resident #4 and immediately reported the incident to the Charge Nurse. The DON was notified, and CNA #2 was suspended pending investigation. Record review also showed the facility grievances dated 5/28/25 to 9/27/25 contained no abuse or neglect issues, and Resident Council Minutes from June 2025 through November 2025 documented one abuse concern in June 2025 with follow-up by administration and no other abuse or neglect issues. Timecards confirmed CNA #2’s last worked shift was 4/27/25 from 6:00 AM to 1:45 PM.
Failure to Send Discharge Notice to Ombudsman
Penalty
Summary
The facility failed to ensure that a copy of residents' discharge or transfer notices was sent to the Office of the State Long Term Care Ombudsman. Review of the facility's Discharge and Transfer policy, revised 4/17/2025, stated that a copy of the discharge notice is sent to the Office of the State LTC Ombudsman after discharge. Appendix PP states that when a facility transfers or discharges a resident, the facility must provide notice to the resident and resident representative and send a copy to the Ombudsman at the same time, while maintaining evidence that the notice was sent. Resident #2 was admitted with multiple diagnoses including atrial fibrillation and urinary tract infection. The record showed a physician order dated 11/28/25 for a planned discharge to home with home health services and continued PT and OT, along with a nursing progress note dated 11/28/25 related to the discharge. On 12/4/25, the CRN stated the facility could not provide documentation showing Resident #2's Notice of Discharge had been sent to the State LTC Ombudsman and said it should have been. The Administrator later presented three email notifications to the Ombudsman dated March 2025, May 2025, and July 2025, and stated there were no other documented notices to the State LTC Ombudsman.
Failure to Refer for Updated PASRR Level II Evaluation After New Serious Mental Disorder Diagnosis
Penalty
Summary
The facility failed to make a referral to the state mental health authority for a possible new PASRR Level II evaluation when a resident was diagnosed with a new serious mental disorder. The facility policy on Resident Assessments PASRR Screening Coordination, dated April 2025, stated that the facility would notify the state designated agency when a resident with a mental disorder experiences a significant change in status and would refer any resident with a newly evident or possible serious mental disorder, intellectual disability, or related condition to the appropriate state designated authority. Resident #6 was admitted with multiple diagnoses including epilepsy, anxiety disorder, and bipolar disorder, and the medical record showed a prior PASRR Level II evaluation from Nevada that documented bipolar disorder, mild mental retardation, epilepsy, and hyperglycemia. Later records documented schizophrenia in the medical history and physical, a Schizophrenia Diagnosis Accuracy Verification Worksheet documenting paranoid schizophrenia, and a care plan problem stating the resident was being treated with psychoactive medication for paranoid schizophrenia and epilepsy. The resident’s record did not document a Level II evaluation that included the diagnosis of paranoid schizophrenia, and the administrator and regional nurse consultant stated the facility had not notified the state mental health authority to request an updated PASRR Level II evaluation when the resident was diagnosed with paranoid schizophrenia.
Failure to Follow Bowel Management Orders
Penalty
Summary
The facility failed to follow physician orders for bowel management for two residents who did not have documented bowel movements within the ordered timeframes. Resident #5 was admitted with diagnoses including depression and anxiety. The physician ordered Miralax on day 3 without a bowel movement, Dulcolax suppository on day 4 if there was still no bowel movement by 4 a.m., and provider notification on day 5 if there was still no bowel movement by 2 p.m. Resident #5 had a documented bowel movement on 11/4/25 at 1:28 AM and then not again until 11/10/25 at 12:17 AM, with over 142 hours without a documented bowel movement. The record did not show that the ordered constipation medications were given on day 4, and there was no documentation that the provider was notified on day 5 as ordered. Resident #21 was admitted with diagnoses including hemiplegia and respiratory failure. The physician ordered the same bowel care sequence: Miralax on day 3 without a bowel movement, Dulcolax suppository on day 4 if no bowel movement by 4 a.m., and provider notification on day 5 if no bowel movement by 2 p.m. Resident #21 had a documented bowel movement on 11/5/25 at 2:49 PM and then not again until 11/12/25 at 5:59 PM, with over 168 hours without a documented bowel movement, and later had another gap from 11/12/25 at 2:49 PM until 11/24/25 at 4:27 PM, over 264 hours without a documented bowel movement. The record did not show that the ordered constipation medications were administered during either period. The DON stated on 12/5/25 that the nurse had not documented bowel medication interventions on the MAR as ordered by the provider for both residents and should have.
Incorrect Oxygen Administration
Penalty
Summary
Resident #7, who was initially admitted and later readmitted to the facility with diagnoses including respiratory failure and depression, had a physician order for oxygen at 2 liters per minute via nasal cannula at bedtime and as needed, with instructions to notify the provider if oxygen saturation was below 90%. During observation on 12/1/25, the resident was seen sitting in bed receiving oxygen at 4 liters per minute via mask, and an LPN stated she was unsure of the ordered oxygen rate but knew the resident was to have oxygen on while in bed and at night. During a later observation on 12/2/25, the resident was again seen sitting in bed receiving oxygen at 3 liters per minute via mask, and a CNA stated she was unsure of the ordered oxygen rate but knew the resident was to receive oxygen while in bed. The RNC later stated the resident's oxygen rate should have been 2 liters per minute via nasal cannula as ordered and had not been.
Nurse Aide Training and Competency Deficiencies
Penalty
Summary
The facility failed to ensure that nurse aides who had worked less than 4 months were enrolled in a State-approved nurse aide training and competency evaluation program (NATCEP), and failed to ensure that nurse aides who had worked more than 4 months had successfully completed a NATCEP. On 12/5/25, 13 nurse aide personnel files were reviewed, and 10 of those files showed deficiencies in training status. NA #1, NA #2, and NA #3 had been hired on 1/6/25, 1/10/25, and 6/18/25, respectively, and had not successfully completed a NATCEP. NA #4 through NA #10 had been hired between 9/30/25 and 11/13/25 and had not enrolled in a NATCEP. During an interview on 12/5/25 at 11:29 AM, the RNC stated that NA #1, NA #2, and NA #3 had not completed the NATCEP course and that NA #4 through NA #10 had not yet enrolled in a NATCEP.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was accurately posted for each shift. During review of the daily postings of licensed and unlicensed nurse staffing for the period from 4/1/25 through 11/30/25, surveyors found that there were no adjustments made 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 that the facility did not make adjustments to the daily postings with actual hours worked and only adjusted the time on the daily assignment sheets.
Missing Signatures on Narcotic Accountability Sheets
Penalty
Summary
Controlled medications were not tracked and kept secure from potential theft and/or diversion on 2 of 2 medication carts reviewed. During the 100 & 200 Hall medication cart audit, the narcotic accountability sheets dated 11/5/25 to 12/1/25 were observed to be missing 2 licensed nurse signatures on 11/25/25 and 11/26/25. During the Dining room & 300 Hall medication cart audit, the narcotic accountability sheets dated 11/26/25 to 12/3/25 were observed to be missing 1 licensed nurse signature on 12/2/25. An LPN stated that two nurses should have signed the narcotic accountability sheet when they accepted or released the medication cart, and the DON stated that two nurses should have signed the narcotic accountability record when they accepted or released the medication cart.
Missed and Delayed Antipsychotic Injection
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when Resident #6 did not receive her Invega Sustenna injection as ordered. Resident #6 was admitted with diagnoses including epilepsy, anxiety disorder, bipolar disorder, and schizophrenia. The physician order, started 2/24/24, directed Invega Sustenna 234 mg IM every 28 days for paranoid schizophrenia. On 10/4/25, the MAR directed staff to see progress notes, and the administration note stated the medication was not available and that pharmacy would deliver it by that night. On 10/5/25, a nurse note documented that the resident received the injection, but it was not documented on the MAR. The record also showed repeated delays in later doses. On 11/1/25, the MAR again directed staff to see progress notes, and the administration note stated the medication was not available at the facility and pharmacy was called, but it was not received. The resident then received the injection on 11/3/25, 29 days after the prior dose. On 12/1/25, the MAR again directed staff to see progress notes, and the administration note stated the shot was not available and day shift would call the pharmacy. On 12/2/25, a nurse note stated the shot still had not come from pharmacy and day shift had not called on it. On 12/3/25 at 6:51 AM, the record documented the injection had not arrived and pharmacy stated there were no refills left on the prescription. The provider was notified for an updated prescription and late administration, and the MAR documented the injection was administered on 12/3/25, 30 days after the previous dose.
Improper Medication, Biological, and Controlled Drug Storage
Penalty
Summary
Medications were not properly stored in the facility medication carts and refrigerator. During an audit of the dining room/300 Hall medication cart, one bottle of Vitamin D was observed with an expiration date of 3/20/25, and one bottle of Aspirin 81 mg contained mixed round yellow tablets and round orange tablets. An LPN stated that two bottles of aspirin had been combined and should not have been. The RNC later stated the expired medications should have been removed from the medication cart and had not been. Biologicals and controlled medications were also not stored as required. One set of glucose test solutions had no opened date, and an LPN stated the bottles should have been dated when opened. The LPN then dated each bottle after the surveyor asked about it. Testing logs showed the glucose test solutions had been opened on 7/5/25 and continued to be used through 11/30/25 for weekly glucometer testing. In addition, two bottles of lorazepam concentrated solution were observed in a removable metal black box on the medication refrigerator shelf, and the RNC stated the controlled medications should have been in an affixed box in the medication refrigerator and were not.
Food Storage, Labeling, and Refrigerator Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was appropriately stored, distributed, and labeled in the kitchen and resident refrigerator. During an initial kitchen observation with cook #1 present, surveyors found an uncovered, undated container of shaved parmesan cheese, open bags of shredded cheddar and Swiss cheese with no opened or use-by dates, a can of dairy whipped topping with no cap and no open or use-by date, and open bags of hotdog and hamburger buns in the storage room with no open or use-by dates. The cook stated the uncovered and undated items should have been covered and dated but were not. During a later kitchen observation with the FSM present, surveyors found cooked shredded turkey in a Ziplock bag dated 11/26/25 with a use-by date of 2/1/26, egg salad half sandwiches in Ziplock bags with smeared, unreadable writing, pureed corn covered in plastic wrap marked only "must use tonight" with no date made or use-by date, potato salad with an expiration date of 12/2/25, yogurt with an expiration date of 10/20/25, and an open bag of corn in an open box inside a chest freezer with no sealed container or dates. The FSM stated several of these items should have been discarded or dated but were not. The dish machine log was also filled out 2 days in advance, and the FSM stated it should not have been completed in advance. In the resident refrigerator, surveyors found Jello pudding cups with expiration dates of 11/6/25 and 11/22/25, and LPN #2 stated they should have been discarded. The resident refrigerator also had dark brown dried material and splattered spills on the shelves and floor, and LPN #2 stated it should have been cleaned and had not been.
Unsafe and Unclean Shower Rooms
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents in 2 of 2 shower rooms, located on the 200 hall and 300 hall. In the 200 hall shower room, surveyors observed a 10-inch x 5-inch x 1.25-inch jagged hole in the floor by the shower stall, with flooring peeling off the surface and not cleanable. They also observed four holes in the middle of the shower room floor, including three 2-inch circular holes and one 4-inch jagged circular hole, with the flooring peeling away and the gaps and crevices containing soiled and darkened matter. In the 300 hall shower room, surveyors observed the left shower stall filled with equipment, including a lift, large bucket, and chair. They also observed a 16-inch x 7-inch x 2-inch jagged hole in the flooring by the entry of the left shower stall and a 12-inch x 2-inch T-shaped hole near the base of the right shower stall, both with peeling flooring and dark-looking matter in the deepest portions. The right shower stall drain had soft brown stool-looking material caught in 3 of the drain screen holes. The large jetted tub had a side panel removed and was not functioning, and a salon chair and workstation were placed at the end of the shower room. The Maintenance Supervisor acknowledged the shower rooms on the 200 and 300 halls needed repairs and stated a work plan had been submitted but not yet approved. The DON stated the shower rooms on the 200 and 300 halls needed to be cleaned and repaired.
Failure to Prevent Abuse and Neglect of a Resident
Penalty
Summary
The facility failed to prevent physical abuse, verbal abuse, and neglect for a resident, identified as Resident #15, who was severely cognitively impaired and had a history of traumatic brain injury. The incident occurred when LPN #1, while assisting the resident, used a gait belt improperly and yelled at the resident to get up. Despite the resident's inability to assist, LPN #1 insisted that the resident could do it and, after a minute of pulling and yelling, expressed frustration and pulled the resident to the floor, causing the resident to hit his head on the door frame. LPN #1 then left the resident on the floor, instructing NA #1 to leave him there, resulting in the resident being left unattended for 45 minutes, during which he was found soaked in urine and saliva. The facility's investigation into the incident was inadequate, as it failed to substantiate the abuse despite clear evidence and witness statements. The former Administrator did not document a physical assessment or monitoring of the resident after the incident, and there was no incident report filed. The attending physician was not notified, and the resident was not sent to the hospital for evaluation. The investigation report concluded that abuse could not be substantiated, although an email from the former Administrator indicated verbal abuse had occurred. The incident was reported to Human Resources the following day, and statements were collected from staff members who witnessed or were informed about the incident. However, the facility's response was delayed and insufficient, as the former Administrator did not take immediate action to protect the resident or ensure proper documentation and reporting of the incident. This failure placed the resident in immediate jeopardy of serious harm, impairment, or death, as the facility did not protect him from abuse and neglect by LPN #1.
Failure to Timely Report Abuse and Neglect
Penalty
Summary
The facility failed to report an allegation of physical and verbal abuse and neglect to the State Survey Agency in a timely manner. This incident involved a resident who was severely cognitively impaired and had a history of traumatic brain injury. The incident occurred when a Licensed Practical Nurse (LPN) was assisting the resident to get off the floor and back into his wheelchair. The LPN was reported to have been rough, yelling at the resident, and eventually pulling him to the floor, causing the resident to hit his head on the door frame. The resident was left on the floor for 45 minutes, soaked in urine, and in pain. The incident was reported by a Nursing Assistant (NA) to the facility's Human Resources personnel the day after it occurred. The NA, along with two other NAs, reported the incident to a Registered Nurse (RN) the following morning, who then provided statements to the former Administrator. The facility's policy required that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, but this was not adhered to, resulting in harm to the resident.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 24 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kimberly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Falls Transitional Care Of Cascadia | 4.2 mi | ★★★★★ | 0 | 0 |
| Serenity Transitional Care | 7.4 mi | ★★★★★ | 0 | 0 |
| Bridgeview Estates | 11.2 mi | ★★★★★ | 0 | 0 |
| Cascades At Desert View | 20.2 mi | ★★★★★ | 24 | 0 |
| Lincoln County Care Center | 27.6 mi | ★★★★★ | 21 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.