Lake Hills Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 6 of 6 (Resident #2, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) residents reviewed for comprehensive person-centered care plans. For Resident #2, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measurable objectives as identified and written in the focus areas of care plan as: [...]

Inspectors wroteBased on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 2 (Caregiver HA A and Caregiver HA D) of 4 Caregiver Hospitality Aides reviewed for nursing services. The facility failed to ensure Caregiver HA A and Caregiver HA D were certified within four months of their hire date. This failure could place residents at risk for receiving inappropriate care from individuals whose skill level was unknown.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure the environment was as free of accident hazards was possible and each resident receives adequate supervision to prevent accidents for 1 of 21 resident (Resident #55) reviewed for accidents and hazards, in that: On 03/20/2025 at about 9:30pm, Resident #55 was able to get out of a window in a common room on the secure unit without staff's knowledge, pull off 3 wood fence pickets and leave the premises. Facility staff were not aware Resident #55 was not in the building until he was returned by law enforcement at approximately 01:00 AM on 03/21/2025. A past non-compliance Immediate Jeopardy (IJ) situation was identified on 04/02/2025 at 3:37 PM. The Immediate Jeopardy began on 03/20/2025 and ended on 03/24/2025. The facility had corrected the non-compliance before the survey began. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: The facility's kitchen staff failed to clean the kitchen as directed by daily cleaning lists. The facility's kitchen staff failed to store food properly. The facility's kitchen staff failed to remove expired food from the refrigerator. The facility's kitchen staff failed to keep clean and dirty dishes separated during meal service. The facility's kitchen staff failed to cover drinks that were placed on delivery trays and sent to the hall during meal service. These failures placed residents at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly notify the resident's physician when there was radiology results outside of clinical reference range for 1 of 5 residents (Resident #17) reviewed for physician notification of radiology results. The facility failed to promptly notify Resident #17's physician by phone per facility protocol on 02/12/25 when x-ray results falling outside of clinical reference ranges reflected Resident #17 had a right femur fracture This failure could place residents at risk of a delay in medical treatment and could result in not receiving appropriate care and interventions.

Inspectors wroteBased on interview and record review the facility failed to provide an activities program directed by a qualified professional for 1 of 1 activity directors (AD) reviewed for qualifications. The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained for 1 of 1 medication rooms reviewed for medication labeling and storage. The facility failed to maintain controlled substance record count sheet with accurate amount of lorazepam (a controlled substance) stored in medication room refrigerator. These failures could place residents at risk of misappropriation of medications. Findings Included: Record review of Resident #3's electronic face sheet dated 01/23/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 01/13/2025 with diagnoses to include: conversion disorder with seizures or convulsions (a mental health condition that causes seizures or convulsions) and anxiety. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 medication rooms reviewed for medication labeling and storage. The facility failed to maintain controlled substance record count sheet with accurate amount of lorazepam (a controlled substance) stored in medication room refrigerator. These failures could place residents at risk of misappropriation of medications. Findings Included: During an observation on 01/23/2025 at 11:48 a.m., the medication room refrigerator had a locked box inside of the refrigerator that was not secured and could be removed easily from the refrigerator. [...]

Inspectors wroteBased on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 (Resident #3) of 6 residents reviewed for resident records. The facility failed to ensure Medication Administration Records were accurate in the electronic medical record for Resident #3. This failure could place residents at risk of having errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #34) of 4 residents reviewed for accident and hazards: The facility failed to ensure Resident #34's bed was on its lowest position while the resident was in his bed. This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues as a result of accident hazards.

Inspectors wroteBased on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that non-potable water was properly labeled and stored in the kitchen. The facility failed to ensure that cleaning supplies were stored separately from food in the kitchen. These failures could affect residents who received meals prepared meals in the kitchen at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean, sanitary, comfortable, and homelike environment in 1 of 2 shower rooms, and 2 of 18 resident restrooms as evidenced by: - 1 of 2 shower rooms did not have a mirror. - Two resident restrooms did not have a mirror. This failure could place the residents who use these restrooms and shower room at risk for a diminished quality of life and a homelike environment.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 (Front medication room) of 2 medication rooms inspected for medication storage. The medication room had expired vial of Tuberculin (TB) medication in the refrigerator. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs in locked compartments for 1 of 1 medications storage compartment. The facility failed to ensure medication carts were locked when unattended for 2 (North hall cart and the Medicare hall cart) of 4 medication carts reviewed for drug storage. The discontinued controlled medications and biologicals kept in the DON's office were not kept behind 2 separate locks at all times. The medication carts for the North and Medicare halls were unlocked and unattended by staff. These failures could place the facility at risk of drug diversion and access to medications or accidental ingestion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #3 and #40) of 13 residents reviewed for infection control. The facility failed to ensure CNA A changed her gloves after they became contaminated while providing incontinent care for Resident #3 and Resident #40. This failure could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and interview the facility failed to prepare, store, distribute, and serve foods in accordance with professional standards for food service safety in the facility's only kitchen reviewed for labeling and storage of food inventory. The facility failed to label and/or date food items stored in freezers, refrigerators, and dry storage areas. The facility failed to remove damaged food cans from inventory and disposed of expired food items. These failures could place residents at risk of contamination, acquiring a food-borne illness, and weight loss.

Inspectors wroteBased on observations, interviews, record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment in 9 of 112 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) and Memory Care Unit hallway. Resident room [ROOM NUMBER] A/B had chipped and scraped walls, rotting/missing baseboards, dirty, grimy, sticky floors, dirty and stained toilet. Resident room [ROOM NUMBER]B had only a recliner with no bed. Resident room [ROOM NUMBER] A/B had broken baseboards, unpainted spackling. Resident room [ROOM NUMBER] had a broken window seal, different shades of paint that did not match, and unpainted spackling. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable and homelike environment for 8 of 24 residents (Resident #18, 33, 40, 43, 46,48,51, 111) and 1 of 2 units (Secure Memory Care Unit) reviewed for safe, clean, comfortable and homelike environment. The facility failed to make repairs to walls or doors for Resident #18. The facility failed to repair door jam for room for Resident #46. The facility failed to properly repair the door jam and door frame for room for Resident #111. The facility failed to place a bed in room for Resident #43. The facility failed to make repairs to chips in walls, or clean room for Resident #33. The facility failed to routinely clean room for Resident #48. The facility failed to repair chipped wood from doors for Rms 62-76 on the Secure Memory Care Unit (SMCU). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a Baseline Care Plan within 48 hours of a resident's admission for 3 of 3 Resident's (#39, #43, and #48's) reviewed for baseline care plan completion. The facility failed to complete baseline care plans for Resident #39, Resident #43, Resident #48 within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk of not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #52 and Resident #7) of 20 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address antipsychotic and antidepressant medication use for Resident #52 and to accurately address the diet texture for Resident #52 who had an order for a mechanical soft diet but was stated to be on a puree diet on the comprehensive care plan. 2. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the diet or swallowing difficulty for Resident #7. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide effective communications mandatory training for 4 of 17 direct care staff (RN E, CNA D, NA C, and DA A) reviewed for training. The facility failed to ensure effective communication training was provided to RN E, CNA D, NA C, and DA A. This failure could affect residents and place them at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its resident for 4 of 17 employees (RN E, CNA D, NA C, DA A,) reviewed for training. The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to RN E, CNA D, NA C, and DA A. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required training on activities that constitute abuse, neglect, and exploitation and misappropriation of resident property and procedures for reporting related incidents for 4 of 17 employees (RN E, CNA D, NA C, DA A) reviewed for training. The facility failed to ensure training on activities that constitute abuse, neglect, and exploitation and misappropriation of resident property and procedures for reporting related incidents was provided to RN E, CNA D, NA C and DA A. This failure could affect residents and place them at risk of abuse, neglect, exploitation or misappropriation of property due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 3 of 17 employees (RN E, CNA D, and DA A) reviewed for training. The facility failed to ensure infection prevention and control training was provided to RN E, CNA D, and DA A. This failure could affect residents and place them at risk of illness due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required compliance and ethics training for 3 of 17 employees (RN E, CNA D, and DA A) reviewed for training. The facility failed to ensure compliance and ethics training was provided to RN E, CNA D, and DA A. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents drug regimen were free from unnecessary drugs for 1 of 5 (Resident #41) reviewed for unnecessary drugs. The facility failed to address pharmacist consultant recommendations for duplicate therapy in the months of December of 21, March of 22, September of 22 for Resident #41 inhaler medications of Symbicort and Advair. The facility failed to discontinue Advair in October of 22 after physician agreed with pharmacist consultant recommendation of duplicate therapy for Resident #41. These findings placed residents at risk of receiving unnecessary medications

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain a system of infection control to prevent infections for 1 of 5 (Resident # 28) reviewed for infection control. LVN-H failed to perform hand hygiene while providing wound care for Resident #28. This failure placed residents at risk for infection of wounds.