Lake Forest Village by Purehealth

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to accommodate Resident #1's needs when they did not ensure her call light was within reach for her to call for assistance. This failure could place residents at risk of not having access to receive necessary assistance, which could affect their dignity and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. Dietary staff failed to dispose of expired foods items in the pantry and refrigerator. Dietary staff failed to ensure the ice machine scooper was clean and sanitized. These deficient practices could place residents at risk for cross-contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for fiscal year 2025 for the first quarter (October 1, 2024, to December 31, 2024) reviewed for one of one facility administration reviewed. The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for October 1, 2024, to December 31, 2024. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to secure confidential medical records for three (Resident #16, Resident #21, and Resident #61) of eighteen residents reviewed for resident rights. The facility failed to ensure LVN I secured Resident #16, Resident #21, and Resident #61's medical information before leaving her cart on 09/10/2025. This failure could place the residents at risk of not having their medical information exposed to unauthorized individuals. Resident #16 Record review of Resident #16's Face Sheet, dated 09/10/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with infection and inflammatory reaction due to other internal joint prosthesis (artificial device that replaces a missing body part). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for four (Resident #7, Resident #9, resident #35, and Resident #37) of fifteen residents reviewed for Care Plans. 1. The facility failed to ensure Resident #7's care plan for diabetes, dated 08/25/2025, had appropriate interventions. 2. The facility failed to ensure Resident #7 was care planned for hypertension. 3. The facility failed to ensure Resident #9's care plan for diabetes, dated 08/25/2025, had appropriate interventions. 4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that medications were stored properly in locked compartments for 4 (Resident #11, Resident #37, Resident #44, and Resident #60) of eighteen residents reviewed for medication storage, 1. The facility failed to ensure Resident #11's zinc oxide (medicated cream used to prevent skin irritation) was not left inside the resident's room on 09/09/2025. 2. The facility failed to ensure LVN A did not leave Resident #37's tramadol inside the resident's room for the resident to take unsupervised on 09/09/2025. 3. The facility failed to ensure Resident #44's zinc oxide was not left inside the resident's room on 09/09/2025. 4. The facility failed to ensure Resident #60's xeroform, petroleum dressing, and calcium alginate were not left inside the resident's room on 09/09/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and 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 for five (Residents #4, #6, #32, #35, and #43) of twelve residents reviewed for infection control. 1. The facility failed to ensure CNA B wore a gown when she transferred Resident #4, who had a catheter, from bed to wheelchair on 09/09/2025. 2. The facility failed to ensure CNA F and CNA G performed hand hygiene and changed their gloves after touching Resident #6's catheter tubing on 09/10/2025. 3. The facility failed to ensure CNA F performed hand hygiene and did not put gloves in her pocket when she assisted Resident #32 on 09/10/2025. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for one (Resident #44) of four residents reviewed for quality of care. The facility failed to ensure that LVN A did not use only one gauze to clean Resident #44's pressure ulcer to her sacrum (bone of the bottom) back and forth, and one gauze to pat dry the pressure ulcer as well as the surrounding skin on 09/09/2025. This failure could place the residents with pressure ulcers at risk for worsening of the existing pressure ulcers and infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the residents were provided medications and/or biologicals and pharmaceutical services to meet their needs for one (Resident #37) of eight residents reviewed for pharmaceutical services. 1. The facility failed to ensure that Resident #37 was not self-administering her Tramadol without assessment on 09/09/2025. 2. The facility failed to ensure that there was no expired medication inside the medication cart since Resident #37's admission to the facility on [DATE]. These failures could place residents at risk of not receiving medications as ordered by the physician, for potential overdose, and adverse effects.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #1 and Resident #2) of eight residents reviewed for respiratory care. 1. The facility failed to ensure Resident #1's breathing mask (used to receive medications by breathing in mist through nose and mouth) used for nebulization (method of delivering medication by converting liquid medication into an inhalable mist) was properly stored when not in use on 07/08/2025. 2. The facility failed to ensure Resident #2's breathing mask was properly stored when not in use on 07/08/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the resident's room for 1 of 4 (Resident #1) reviewed for pest control. The facility failed to keep an effective pest control program to ensure Resident #1's closet was free of ants. These failures could place residents at risk for insect bites, skin irritations, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according to guidelines. The facility failed to ensure that staff was wearing the proper head coverings when serving food. The facility failed to ensure proper discarding of expired food stored in the refrigerator and freezer storage area. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings on 06/20/23 at 08:45 AM include: Four small bowls of garden salad was uncovered and unlabeled in the refrigerator. [...]