Hidden Lakes Senior Living Community

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow the menu for 1 of 3 observed meals, as evidenced by the failure to follow the recipes for the main entree of Beef Quesadilla and the alternate entree of Savory Baked Chicken Thigh. This resulted in a food complaint by 2 of 10 sampled residents, Resident #7 and a resident who requested to be anonymous. The Certified Dietary Manager (CDM) also added mashed potatoes and gravy to the alternate meal without following their documented process.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect 18 residents who ate food by mouth. The census at the time of survey was 18.

Inspectors wroteBased on observation and interview, the facility failed to maintain the dumpster area in a clean and sanitary condition as evidenced by the failure to dispose of garbage and refuse properly. This failure had the potential to attract pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to service food at a safe and palatable temperature for 2 of 3 sampled residents who were served milk during the lunch meal on 02/04/26, Residents #3 and #16, and as evidenced by kitchen processes resulting in resident complaints of cold food by Resident #7, #2, and #10.

Inspectors wroteBased on observation, menu review, and interview, the facility failed to ensure food was prepared to meet the needs for 3 of 3 sampled residents observed, as evidenced by the failure to provide and serve chopped meat to Resident #2 and #21, and failure to cut up meat to bite-sized pieces for Resident #5. The kitchen staff also failed to prepare ground meat on 02/02/26 as per the mechanical soft diet menu. This failure had the potential to affect 7 residents who were on physician ordered mechanical soft diets.

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for 2 of 10 sampled residents, as evidenced by the inaccurate assessment for range of motion ability, diagnoses, and terminal illness status for Resident #7, and for range of motion ability for Resident #6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely assess, monitor, document care, and notify the physician for a resident who exhibited cold-like symptoms for 1of 1 sampled resident, Resident #2, reviewed for change of condition. In addition, the facility failed to assess and document blood pressure prior to administering antihypertensive medication as required by the physician order for 1 of 5 sampled resident, Resident #2, reviewed during the unnecessary medication review task.

Inspectors wroteBased on record review, staff interview, and review of the policy and procedure, the facility failed to ensure supervision and implementation of interventions to prevent falls for 1 of 1 sampled resident, Resident #20, which resulted in the resident sustaining 3 falls within 5 weeks.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to follow the physician's order for feeding tube flush and to obtain weekly weights for 1 of 1 sampled resident, Resident #6, which was required to maintain the resident's nutritional needs and prevent complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of foods as per resident preference for 2 of 4 sampled residents, as evidenced by the failure to ensure ice cream and mashed potatoes daily for Resident #16, and failure to ensure double portions for Resident #2.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean, comfortable and homelike environment related to dirty carpet in 3 of 18 resident rooms (room [ROOM NUMBER], #9 and #14) and 1 of 24 bedside tables having 1 of 4 bolts missing from the table's surface (room [ROOM NUMBER]).

Inspectors wroteBased on record review and interview, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment for 1 of 5 sampled residents, related to the medication usage of Resident #9.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to: a) provide showers per resident schedule and/or resident choice for 3 of 3 sampled residents reviewed for Activities of Daily Living (ADL) care (Resident #122, #72, and #14); and b) provide timely nail care to 1 of 1 sampled residents reviewed for ADL's related to nail care (Resident #122)

Inspectors wroteBased on record review, documented monthly pharmacy reviews, and interviews, the consultant pharmacist failed to identify the lack of behavior monitoring for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #9).

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate monitoring of medications for 2 of 6 sampled residents. The facility failed to ensure behavior monitoring for psychotropic medication use for Resident #9, and failed to ensure appropriate antibiotic use for Resident #14.

Inspectors wroteBased on record review and interview, the facility failed to complete physician ordered laboratory services timely for 2 of 5 sampled residents reviewed for unnecessary medications (Resident #9 and #72).

Inspectors wroteBased on observation, interview and policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 1 sampled resident with an indwelling catheter (Resident #14).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate and current menu was posted for residents who eat their meals at the facility.

Inspectors wroteBased on clinical and administrative record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This is evidenced by the facility failure to follow the established protocols and policy and procedure regarding COVID outbreak testing and follow-up.

Inspectors wroteBased on clinical and administrative record review and staff interview, the facility failed to ensure the clinical record provided documentation or evidence that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. [...]

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary comfortable environment and help prevent the development and transmission of communicable diseases and infections, as evidenced by the failure to ensure proper infection surveillance related to numerous Urinary Tract Infections (UTI's) in [DATE], for 3 of 4 sampled residents, affecting Residents #12, #13, and #23; failure to ensure appropriate Transmission Based Precautions for 1 of 1 sampled resident, Resident #4 who had Methicillin Resistant Staphylococcus Aureus (MRSA) of a wound; failure to ensure contact tracing with supplemental testing for the last COVID-19 positive staff identified (Staff G, cook); [...]

Inspectors wroteBased on record review and interviews, the facility failed to implement and develop individualized care plans for 3 of 10 sampled residents. Specifically,related to nutrition for Resident # 1 and Resident #7, pressure ulcers for Resident #1 and Hospice Services for Resident #13.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate care and services for 2 of 10 sampled residents. Coordination between Hospice and facility nurses related to the suprapubic catheter of Resident #13 was not maintained. Facility nurses failed to notify the physician of a hypertension (increased blood pressure) medication being held two days in a row for Resident #8.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the provision of wound care was rendered, as per ordered, and failed to ensure coordination of care between the wound care physician and facility nurses for 1 of 1 sampled residents (Resident #1).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to safely store wound care medications and supplies for 2 of 2 sampled residents receiving wound care (Residents #13 and #1), and failed to ensure expired supplements and laboratory supplies were removed from 1 of 1 medication storage rooms. A random observation on [DATE] revealed the treatment cart was left unattended and unlocked.

Inspectors wroteBased on record review and staff interviews, the facility failed to: 1) Accurately document the number of Certified Nursing Assistants (CNAs) directly responsible for resident care and the actual hours worked by the CNA's on the 6:00 AM - 2:00 PM shift on 2 of 14 days reviewed in May 2023; and 2) Post the total number of nurses and CNA's working each shift on the Nurse Staffing Information document.

Inspectors wroteBased on record review and interview, the facility failed to ensure documented evidence of the provision of the influenza vaccine for 4 of 5 sampled residents, was maintained in the medical record (Residents #8, #11, #12 and #14).