Blue Lake Post Acute

Inspectors wroteBased on interviews and record review, the facility failed to designate a full time Director of Nursing (DON) as required, leaving the position vacant from 1/19/26 through 4/5/26.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that nurse staffing information posted for public viewing was current.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Provide evidence of an ongoing water management program for the entire facility, 2) Ensure alcohol-based hand sanitizer dispensers were not expired on all wings of the facility, 3) Ensure enteral nutrition tubing was not exposed to potential pathogens in the environment for one (Resident #9) of one resident receiving continuous tube feeding, and 4) Ensure one (Resident #5) of one resident reviewed out of four residents with urinary catheters, received appropriate care for handling the tubing and collection bag to prevent the potential for infection in a sample of 34 active residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure six (Residents #7, #8, #38, #45, #52, and #59) of twenty four resident records reviewed, contained evidence of a quarterly assessment completed using the State specified instrument approved by CMS (Centers for Medicare and Medicaid Services) at least every three months.

Inspectors wroteThe facility failed to ensure that drug regimen irregularities identified by the Consultant Pharmacist were reviewed and acted upon by the attending physician, Medical Director, and Director of Nursing (DON). This failure resulted in unaddressed medication irregularities for four (Residents #5, #38, #6 and #2) of seven residents reviewed for their medication regimens. This created the potential for adverse drug outcomes.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure care was provided in a manner that maintained resident dignity for one (Resident #1) of four residents reviewed for dignity, when the resident's indwelling urinary catheter drainage bag was left uncovered. This failure had the potential to affect four residents in the facility with urinary catheter bags.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were assessed for safe self-administration of medication as clinically appropriate for medications left at bedside for two (Residents #59 and #55) of two residents reviewed for self-administration of medications out of 34 active sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a safe, clean, and comfortable environment when resident room equipment was observed with significant dust accumulation, affecting four residents (#38, #18, #5, and #54) with the potential to affect the facility's remaining 47 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one (Resident #54) of one resident reviewed for rehabilitation/restorative services received necessary care and services, when a physician-ordered left-hand brace was not available and had not been applied as ordered.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its medication error rate was not 5% or greater. The facility's medication error rate was calculated at 36%, based on 11 medication errors observed out of 30 opportunities for error.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to 1) Ensure refrigerated medications were stored in a locked compartment, and 2) Ensure Schedule II-V controlled medications were secured within a fully protected, double locked system. Schedule II-V controlled medications are substances with accepted medical use that have potential for abuse and may lead to physical or psychological dependence. Although the controlled medications were stored in a separately locked, permanently affixed inner compartment, the refrigerator housing that compartment was left unlocked, resulting in inadequate security.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that eight (Residents #1, #2, #3, #4, #5, #6, #7, and #8) of eight residents reviewed for foot care were provided with foot care consistent with professional standards of practice, including assisting residents in making necessary appointments with qualified healthcare providers such as podiatrists. Failure to provide appropriate foot care can result in ingrown toenails, fungal infections, skin infections, and can potentially impact the resident's dignity and sense of self-worth.

Inspectors wroteBased on observations, a review of resident and facility records, interviews with staff, and a review of job descriptions and facility policies and procedures, the facility failed to protect the resident's right to be free from sexual abuse from a resident. This resulted in sexual contact for one resident who was unable to consent to sexual activity (Resident #1) of three residents reviewed for abuse. The facility failed to develop and implement interventions necessary to protect Resident #1 from sexual contact by Resident #2, who had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment, and who was independently ambulatory with the use of a cane. [...]

Inspectors wroteBased on staff interviews, resident and facility record reviews, and a review of facility policies and procedures, the facility failed to thoroughly investigate sexual abuse for one (Resident #1) of three residents reviewed for abuse. Failure to investigate sexual abuse thoroughly, put the facility's female residents at a likelihood for suffering sexual abuse, which could result in serious psychosocial harm, which would diminish their self-worth and self respect. Immediate Jeopardy (IJ) at a scope and severity of J (isolated) was identified on April 7, 2025 at 3:50 p.m. On April 1, 2025, at 6:55 p.m., Immediate Jeopardy began. On April 8, 2025, at 6:15 p.m., the Administrator was notified of the IJ determination and was provided with Immediate Jeopardy Templates. Immediate Jeopardy was ongoing as of the survey exit on April 8, 2025.

Inspectors wroteBased on staff interviews, resident and facility record reviews, and a review of job descriptions, the facility's administration failed to ensure that staff provided appropriate supervision to protect vulnerable residents from sexual abuse for one (Resident #1) of three residents reviewed for abuse. The facility administration failed to ensure that staff developed and implemented interventions necessary to protect Resident #1, who was unable to consent, from sexual contact by Resident #2. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment, and was independently ambulatory with the use of a cane. This created a likelihood that Resident #1 or any other vulnerable resident could be sexually assaulted and suffer serious psychosocial and/or physical harm from Resident #2. [...]

Inspectors wroteBased on staff interviews, resident and facility record reviews, and a review of facility policies and procedures, the facility's Quality Assessment and Quality Assurance Committee (QAA) failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that caused adverse outcomes. This resulted in a lack of improvement of their systems and processes. This failure contributed to the sexual abuse of one (Resident #1) out of three residents reviewed for abuse. It also placed all other vulnerable female residents at a likelihood for serious adverse outcomes related to potential sexual abuse from Resident #2. Immediate Jeopardy (IJ) at a scope and severity of J (isolated) was identified on April 7, 2025 at 3:50 p.m. On April 1, 2025, at 6:55 p.m., Immediate Jeopardy began. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations related to abuse were reported immediately, but not later than two hours after the allegation was made, to officials (including the State Survey Agency). The facility also failed to report the results of the investigations to the State Survey Agency within five working days of the incidents. This involved three (Residents #1, #2, and #3) of three residents reviewed for abuse, from a total survey sample of eight residents. Reporting requirements under this regulation are based on real (clock) time, not business hours.

Inspectors wroteBased on a review of closed resident records, facility policies and procedures, and interviews with the resident and staff, the facility failed to provide and document sufficient preparation and orientation to one (Resident #2) of three residents reviewed, to ensure a safe and orderly discharge from the facility.

Inspectors wroteBased on observations and interviews with staff, the facility failed to store refrigerated food in a manner to prevent contamination by airborne matter, by failing to ensure the evaporator fan was clean and free of build-up and debris. This had the potential to effect all 42 residents in the facility who ate by mouth, by potentially contaminating exposed food with the built-up matter on the fan.

Inspectors wroteBased on a facility record review and a staff interview, the facility failed to maintain documentation to demonstrate evidence of its ongoing Quality Assurance Performance Improvement (QAPI) program. This failure could potentially affect all facility residents.

Inspectors wroteBased on a review of resident records and an interview with staff, the facility failed to comprehensively assess residents' strengths, needs, preferences, and goals within the required timeframes for five (Residents #18, #21, #23, #24, and #38) of nine residents whose Minimum Data Set (MDS) assessments were reviewed, from a total survey sample of 34 residents.

Inspectors wroteBased on a review of resident records and an interview with staff, the facility failed to comprehensively assess residents' strengths, needs, preferences, and goals quarterly for four (Residents #15, #14, #9, and #42) of nine sampled residents whose Minimum Data Set (MDS) assessments were reviewed, from a total survey sample of 34 residents.

Inspectors wroteBased on a review of resident records and an interview with staff, the facility failed to notify the resident and/or the resident's representative of an emergency hospital transfer and the reasons for the transfer in writing, and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman (LTCO) for one (Resident #103) of two residents reviewed for transfer/discharge, from a total survey sample of 34 residents.

Inspectors wroteBased on a review of resident records and an interview with staff, the facility failed to provide written information to the resident and/or the resident's representative on the facility's bed-hold policy and the duration the resident's bed would be held while she was in the hospital for one (Resident #103) of two residents reviewed for transfer/discharge, from a total survey sample of 34 residents.

Inspectors wroteBased on record reviews, staff interviews, and facility policy review, the facility failed to refer residents with newly diagnosed serious mental illnesses to the state-designated authority for a new Pre-admission Screening and Resident Review (PASRR) Level II screening, to ensure appropriate care and services were prescribed for three (Residents #25, #40, and #47) of four residents reviewed for PASRR compliance, from a total survey sample of 34 residents.

Inspectors wroteBased on record review, observations, and interviews with staff, the facility failed to identify and minimize the risk of accidents, and provide supervision to prevent accidental injury, for one (Resident #18) of one resident reviewed for accidents, from a total survey sample of 34 residents.

Inspectors wroteBased on observations, staff interviews, record reviews, and facility policy review, the facility failed to implement a process for on-going infection control and prevention, including enhanced barrier precautions, to prevent the spread of infection for two (Residents #38 and #22) of five residents sampled during a review of the facility's infection prevention and control program, from a total of 34 residents in the survey sample. The finds include: 1. A review if Resident #38's medical record revealed he was admitted to the facility on [DATE] with an indwelling urinary catheter and diagnoses including multiple sclerosis, neuromuscular dysfunction of bladder, and reflex neuropathic bladder. A review of the resident's Progress Notes revealed that the resident completed a course of antibiotics on 6/29/2024 related to a complicated urinary tract infection (UTI). [...]

Inspectors wroteBased on record reviews, interviews, and a review of the policy and procedure for Behavior Monitoring, the facility failed to ensure that two (Residents #40 and #17) of five residents selected for unnecessary medication review, from a total sample of 18 residents, were receiving behavior monitoring for psychotropic medications.