Lake Country Health Services

Inspectors wroteBased on observation, interview and record review the facility did not ensure its medication error rate was below 5%. The facility error rate was 7.69% affecting 2 residents (R12 and R67) observed during medication pass.

Inspectors wroteBased on observation and interview the facility did not provide routine and emergency drugs and biologicals to meet the needs of each resident for 3 of 4 medications carts observed.

Inspectors wroteBased on record review and interviews, the facility failed to honor a resident's advanced directive of do not resuscitate for 1 (R1) of 4 residents reviewed for advanced directives and resident's rights. R1 has a State Do Not Resuscitate (DNR) form signed by R1's Power of Attorney (POA), and an active Medical Doctor (MD) order documenting DNR. On [DATE], R1 became unresponsive and was pulseless. Facility staff did not check R1's advanced directives before performing Cardiopulmonary Resuscitation (CPR) compressions on R1. R1's pulse returned. After receiving compressions, R1 complained of pain as high as 10 out of 10 and required an added MD order for Morphine to control R1's pain. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to have a policy and procedure in place to ensure the code status of residents, as indicated in their advanced directives, was followed. This affected 1 (R1) of 1 residents reviewed for Cardiopulmonary Resuscitation. The facility's phone paging system, which is used to alert all staff of a code blue, was observed not working during survey. The facility's portable phones, which can also be used to alert all staff of a code blue, were not functional on all the units within the facility. The facility's overhead speaker system has not been functional for years. This deficient practice has the potential to effect 27 out of 82 residents who have designated to have full code status (designated to receive cardiopulmonary resuscitation [CPR]) in the facility. *The facility does not have a Code Blue policy and procedure. [...]

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R1) of 4 residents were free from significant medication errors. *On [DATE], R1 was prescribed scheduled morphine due to severe chest and back pain. On [DATE], R1 was not administered the full dosage of their scheduled morphine for four consecutive opportunities.

Inspectors wroteBased on record review and interviews, the facility did not ensure that 1 out of 1 resident (R1) reviewed for abuse allegations was free from exploitation, abuse of power, and mental abuse. A facility Certified Nursing Assistant (CNA-C) and R1 exchanged phone numbers and began a friendship which included several text messages between the two individuals over several months. CNA-C and R1 continued with the relationship to the point that R1 believed CNA-C was his girlfriend and that he would eventually leave the facility and they would live together. CNA-C often visited R1 in his room while she was working and assigned to other units. CNA-C and R1 did become intimate, often talking sexually in text messages, sharing several kisses, laying under covers with one another, and touching in a sexual manner. CNA-C purchased gifts for R1 and would visit even when she was not working. [...]

Inspectors wrote3) On 10/23/24 at 9:10 AM, Surveyor asked Director of Nursing (DON)-B for the faciliy's neuro-check policy. Nursing Home Administrator (NHA)-A returned to surveyor and informed surveyor that the incident involving the Hoyer lift bar hitting R5's head would be addressed in the fall policy under the neuro-checks section. NHA-A stated the facility does not have a separate neuro-check policy. The facility policy entitled, Fall Prevention and Management Guidelines with a review date of 7/18/24, documents, in part: . Neuro checks for any unwitnessed fall or witnessed fall, where resident hits their head: Initially, then hourly x 3, then continue neuro checks every 4 hours x 6, then continue neuro checks every 8 hours x 6 or as indicated by the physician. Alert MD (Medical Doctor) of any abnormal findings from neuro checks- do not wait until series is complete to notify MD of abnormal findings. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 2 of 2 residents (R14 & R5) received adequate supervision and assistance devices to prevent accidents. * R14 was admitted to the facility on [DATE] with a fracture of right pubis and history of falls. The facility did not develop a person centered falls care plan and this care plan did not address R14 self transferring. On 7/17/24, R14 attempted to self transfer, fell, and was transferred to the hospital. The hospital ED (emergency department) notes document a new sacral fracture. * R5 was transferred by 2 Certified Nursing Assistants (CNAs), CNA-CC and CNA-DD, via a Hoyer lift on 9/6/24. During the transfer, the bar from the Hoyer lift hit R5's head causing pain. R5 was sent to the emergency room (ER) for evaluation. R5 returned to the facility with a diagnosis of a mild concussion. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure that they reported allegations of sexual abuse and exploitation to Nursing Home Administrator (NHA)-A and to the State Survey Agency. This occurred for 1 of 1 resident reviewed (R1). Facility staff became aware of a relationship between R1 and CNA (Certified Nursing Assistant)-C that included months of communication via phone calls, text messages, and in-person visits to the resident's room. CNA-C would often visit R1 while working at the facility when she was not assigned to his unit. By the staff not reporting to Administration what they had heard and observed, it allowed the alleged perpetrator (CNA-C) continued access to R1. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not always ensure allegations of abuse/exploitation were thoroughly investigated for 2 out of 2 residents reviewed (R1, R6). * Facility staff became aware of a relationship between R1 and CNA (Certified Nursing Assistant)-C that included months of communication via phone calls, text messages, and in-person visits to the resident's room. CNA-C would often visit R1 while working at the facility when she was not assigned to his unit. By the staff not reporting to Nursing Home Administrator (NHA) what they had heard and observed, it allowed the alleged perpetrator (CNA-C) continued access to R1. When NHA did become aware that R1 and CNA-C had exchanged phone numbers, they failed to thoroughly investigate the situation by talking with staff who may have knowledge of the incident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. There were observations of call lights not being answered for an extended period of time, Director of Nursing (DON)-B expressed concern regarding nurse staffing levels, record review and residents expressing concerns regarding lack of sufficient staff. The facility had low staffing on night shift on 10/1/24 and 10/4/24, while having a census of 74 and 75 residents. R2 did not receive a scheduled shower on 9/26/24 due to short staffing.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R2) of 1 resident's resident representative was notified when there was a need to alter medical treatment. R2's POA (Power of Attorney) was not notified when there was a change in R2's pain medication.

Inspectors wroteBased on observation, interviews, and record review the facility did not address and resolve grievances conveyed on behalf of 2 (R9 and R12) of 5 residents reviewed for grievances. * On 10/18/2024, a grievance was initiated for R9 related to R9 having concerns with not being checked on night and being double briefed on night shift. Surveyor noted the grievance form documented the grievance was resolved, but R9 continued to express concern to Surveyor of on-going issue and Surveyor observed R9 saturated in urine in the morning on 10/23/2024. * R12 informed Surveyor of concerns that R12 is not getting up before 06:00 AM, as care planned, and has not been updated on a concern R12 voiced regarding a room change discussed with the Facility.

Inspectors wroteBased on interview and record review, the facility did not ensure their admissions policy was followed for 1 resident (R16) of 1 residents reviewed. * R16 was admitted on [DATE] and did not sign the admission agreement within 48 hours which includes but not limited to: consent to treat, financial agreement, and resident rights. Findings Include: The facility's admission Policy implemented 10/1/18 and last revised on 11/1/23 documents: Policy : All facilities must follow the policy and procedures for all admissions to mitigate bad debt risk. The admission process sets the precedent for all the billing and collection process. The Executive Director will delegate the admission process to the appropriate individual(based on staffing pattern of the facility). This individual must ensure that both clinical and financial assessments are completed before any admission decision. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R16) of 16 Residents reviewed had a comprehensive care plan that was reviewed and revised by the interdisciplinary team as determined by the Resident's assessed needs. R16's care plan was not revised to accurately identify R16's at risk for pressure areas/skin impairments, the need for a toileting plan, and discharge planning interventions. Findings Include: 1.) R16's admission Minimum Data Set(MDS) completed on 9/23/24 documents R16 has a Brief Interview for Mental Status(BIMS) score of 15, indicating R16 was cognitively intact for daily decision making. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. R16 required substantial/maximum assistance for shower/bathing, lower dressing, personal hygiene, rolling left to right, and sit to lying. [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement an effective discharge planning process focusing on resident discharge goal, preparation for transition and reduction in factors leading to preventable readmission for 1 resident (R16) of 1 residents reviewed for discharge planning. * The facility did not complete the admission process for R16 and/or representative including explaining R16's available benefits at time of admission detailing that R16 would either need to private pay as of 10/18/24, or the facility would need to assist R16 with an effective discharge plan for 10/18/24. R16 was notified at 8:45 AM on 10/17/24 the option of private pay or discharge home effective 10/18/24. R16 chose to discharge home on [DATE]. Findings Include: The facility's Transfer and Discharge Policy implemented June 2017 and last revised on 7/15/22 documents: [...]

Inspectors wroteBased on observation, interview, and record review the facility did not provide the necessary ADL (Activities of Daily Living) services for 3 (R7, R11, and R13) of 17 residents who were dependent on staff to provide ADL care. R7 is dependent for bathing and R7 did not receive showers on 9/8/24 and 9/15/24. R11 is dependent for bathing and R11 received 2 showers for the month of September 2024. R13 is dependent for continence care and did not receive continence care multiple times in July 2024.

Inspectors wroteBased on interview and record review, the facility did not ensure residents with urinary incontinence were comprehensively assessed to receive appropriate treatment and services to prevent complications and restore continence to the extent possible for 1 (R16) of 1 Resident reviewed for incontinence. * A bladder assessment and care plan with person centered interventions was not implemented when R16's urinary continence declined from occasionally incontinent to frequently incontinent. Findings Include: 1.) R16's admission Minimum Data Set (MDS) completed on 9/23/24 documents R16 has a Brief Interview for Mental Status(BIMS) score of 15, indicating R16 was cognitively intact for daily decision making. R16's MDS documents R16 had no range of motion impairments. R16 was independent for eating. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure therapy services were provided in a timely manner for 2 (R4 and R16) of 2 residents reviewed for therapy services. *R4 returned to the facility on 7/25/24 after receiving Cortisone (a steroid medication that can help with pain and inflammation) injections to both knees. R4's orthopedic doctor advised that R4 should start Physical Therapy (PT). R4 did not start PT until 9/5/24. *R16 did not receive a home evaluation before discharge.

Inspectors wroteBased on interview and record review the facility did not provide a written notice of transfer, including the reason for transfer and appeal rights to the resident, and their representatives, at the time of transfer from the facility. This was observed with 7 (R49, R51, R58, R3, R4, R55, R75) of 7 residents reviewed for transfers. * R49 was transferred to the hospital on 2/3/24 and was not provided a written notice of the transfer including reason for the transfer and appeal rights. * R51 was transferred to the hospital on 4/5/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. * R58 was transferred to the hospital on 6/15/24 and was not provided a written notice of transfer including reason for the transfer and appeal rights. [...]

Inspectors wroteBased on record review and interview, the facility did not provide the written bed-hold requirements to the resident, or their representatives, at the time of transfer from the facility. This was observed with 5 (R49, R51, R58, R55, R75) of 7 resident transfers reviewed. * R49 was transferred to the hospital on 2/3/24 and was not provided the written bed-hold notification. * R51 was transferred to the hospital on 4/5/24 and was not provided the written bed-hold notification. * R58 was transferred to the hospital on 6/15/24 and was not provided the written bed-hold notification. * R55 was transferred to the hospital on 5/4/24 and was not provided the written bed-hold notification. * R75 was transferred to the hospital on 4/21/24 and was not provided the written bed-hold notification.

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's record reflected the accurate resuscitation code status election for 1 (R8) of 18 residents reviewed for code status. R8's hospital discharge paperwork dated [DATE] and facility admission documentation completed on [DATE], indicated R8 elected a full code status. On [DATE] R8's medical record documented a DNR (Do Not Resuscitate) MD (medical doctor) order. After the facility conducted a meeting with R8's POA (power of attorney)-K, R8's code status was changed to a full code and a new full code MD order was placed in R8's medical record on [DATE] per R8's POA-K wishes. On [DATE], R8's code status was changed to DNR. R8's progress notes continue to document R8 is a full code despite the signed paperwork and active MD order for DNR.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 (R7) of 8 residents reviewed for pressure injuries. R7 was re-admitted to the facility from the hospital on 7/19/2023, with a stage 2 pressure injury to the coccyx. The facility did not complete a comprehensive assessment of the pressure injury including measurements and a description of the wound bed documented upon re-admission. R7 had 2 additional re-admissions to the facility from the hospital on [DATE] and 10/12/2023. The facility did not complete a comprehensive assessment of the pressure injury with measurements and description of the wound bed documented upon readmission for these two additional re-admissions.

Inspectors wroteBased on interview and record review, the facility did not ensure the environment remained free of accident hazards for 1 (R3) of 6 residents reviewed for accidents. * R3 fell from bed while receiving cares due to bed frame not being extended to accommodate mattress size. R3 has bed rails attached to frame but there is no maintenance plan in place by facility for inspection after installation.

Inspectors wroteBased on observation, interviews and record review, the facility did not ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight for 1 of 2 (R69) residents reviewed for weight loss. R69 was not weighed as ordered. R69 sustained severe weight loss over a period of less than 2 months. Neither the Physician, nor the Dietician was notified and no new interventions were implemented. R69 continued to lose weight with no Physician or Dietician notification and no new interventions were implmented until an additional month later.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R27) of 3 residents was provided with pain management consistent with professional standards of practice. R27 reported being in constant pain. The facility did not identify R27 was assessed to have a significant worsening of pain effecting R27's quality of life while conducting R27's Minimum Data Set (MDS) Pain assessments on 5/13/24. R27 was hospitalized on [DATE] and was readmitted to the facility on [DATE]. R27 did not have an order for scheduled Tylenol order from 5/9/2024 through 6/3/2024 or Tramadol which was in place prior to R27's hospitalization. The facility did not address the potential for R27 to experience increased pain with the change in pain medication orders. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure Registered Pharmacist consult recommendations were acted upon promptly, and relayed to the required staff. This was observed with 2 (R58 and R3) of 5 resident medication reviews. * R58 and R3 had Registered Pharmacist (RPH) medication regimen review recommendations that were not relayed to the Physician, Medical Director and Director of Nurses, promptly.

Inspectors wroteBased on observation and interview the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and including labeling drugs and biologicals with the expiration date when applicable. This was observed with 2 (R45 and R55) of 2 residents reviewed who receive insulin. R45 and R55 each had 2 open insulin pens in their respective medication cart that were not labeled with an open or use by date.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one of 10 sampled residents (Resident (R) 1) was fully informed of the risks and benefits of proposed care and treatment options and was given the right to choose her preferred option when her antibiotic regimen was altered.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the physician was notified when multiple administrations of antibiotics and probiotics to treat a recurrent Clostridioides difficile [C. diff, a bacterial infection known to cause diarrhea and colitis (inflammation of the colon)] were not available for administration for one of 10 sampled residents (Resident (R) 1). This delayed the physician from altering R1's course of treatment when a new antibiotic course was not initiated.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one of 10 sampled residents (Resident (R) 6) who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when R6 missed four of five showers during her admission to the facility.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure medications were available for administration for one of 10 sampled residents (Resident (R) 1). R1 missed multiple administrations of antibiotics and probiotics to treat a recurrent Clostridioides difficile [C. diff, a bacterial infection known to cause diarrhea and colitis (inflammation of the colon)].

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record accurately reflected the resident's refusals to be weighed and physician notification of weight changes for one of 10 sampled residents (Resident (R) 5).

Inspectors wroteBased on record review and staff interview, the facility did not ensure allegations involving potential abuse were thoroughly investigated for 3 Residents (R1, R7, and R10) of 3 Residents reviewed for allegations of abuse. * On 9/29/23, an allegation of abuse involving R1 was reported to Director of Nursing(DON-B), but was not thoroughly investigated by the facility. * Certified Nursing Assistant(CNA)-E reported to nurses that R7 was upset and tearful because R7 was being forced to go to bed when R7 did not want to and the facility did not thoroughly investigate the allegation. The accused CNA-C was allowed to continue to work with other residents with no provision as to how the facility would protect other residents from potential further abuse. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 allegations of mistreatment or abuse involving 3 Residents (R1, R7, and R10) were reported immediately to the State Survey Agency. * On 9/29/23, an allegation of abuse involving R1 was reported to Director of Nursing (DON-B), but was not reported to the State Survey Agency. * Certified Nursing Assistant (CNA-E) reported to nurses that R7 was upset and tearful because R7 was being forced to go to bed when R7 did not want to. * On 9/3/23, an allegation of abuse involving R10 was reported to DON-B and Administrator (NHA-A), but was not reported to the State Survey Agency. Findings Include: Surveyor reviewed the Abuse, Neglect, and Exploitation policy and procedure revised 7/15/22 and notes the following in regards to reporting: .IV. Identification of Abuse, Neglect, and Exploitation A. [...]

Inspectors wroteBased on record review, and staff interview, the facility did not maintain records that were complete and accurately documented for 1 (R9) of 2 residents reviewed who received cardiopulmonary resuscitation (CPR) in the facility. * R9 received CPR after a cardiac arrest on [DATE] and nothing about the event was documented in R9's medical record.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 70 residents residing in the facility. The facility did not have a practice of monitoring and documenting food holding temperatures.

Inspectors wroteBased on observation and staff and resident interview, the facility did not ensure food was served at a palatable temperature and was appetizing for 9 Residents (R) (R8, R17, R1, R54, R56 R175, R176, R24, and R15) of 12 residents. R8, R17, R54, R56, R1, R176, R24, and R15 stated their meals were not served at a palatable temperature and/or the food was not appetizing. In addition, R175's lunch meal contained items that were warm, lukewarm and cool to taste.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure accurate administration of medication for 3 Residents (R) (R15, R7 and R21) of 5 residents reviewed. R15 did not consistently receive pain medication timely as ordered by R15's physician. R7 did not consistently receive medication timely as ordered by R7's physician. R21 did not consistently receive medication timely as ordered by R21's physician.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R45) of 5 residents was monitored for the effectiveness and potential side effects of psychotropic medications. R45 was admitted with diagnoses that required use of multiple psychotropic medications. The facility did not monitor for the effectiveness or potential side effects of the medications.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 4 errors occurred during 28 opportunities which resulted in a 14.29% medication error rate affecting 2 Residents (R) (R7 and R21) of 3 residents observed during medication pass. R7 had physician orders for Baclofen (a muscle relaxant) 10 mg (milligram) tablet four times a day scheduled at 7:00 AM, 11:00 AM, 3:00 PM and 7:00 PM, Tizanidine (a muscle relaxant) 3 mg tablets three times a day scheduled at 8:00 AM, 12:00 PM and 8:00 PM, and Eliquis (used to prevent blood clots) 5 mg tablet two times a day scheduled at 8:00 AM and 7:00 PM. During an observation of medication administration, Surveyor noted R7's AM medications were not administered until 11:20 AM. [...]

Inspectors wroteBased on observation and staff interview, the facility did not staff performed appropriate hand hygiene during a care observation for 1 Resident (R) (37) of 2 sampled residents with an indwelling catheter. Staff did not perform appropriate hand hygiene during an observation of care for R37.