Lake Park Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 1) of three sampled residents' hospital discharge orders were verified with admitting physician upon Resident 1's admission to the facility in accordance with professional standard of practice when Resident 1's admission order was not clarified and transcribed accurately and Resident 1 did not received medications as ordered. This failure resulted in Resident 1 not receiving medications as ordered by the physician for three days and Resident 1's transfer to the hospital for syncope (fainting or passing out). During a review of Resident 1's admission Record (AR), dated 2/13/26, the AR indicated Resident 1 was admitted to the facility in January 2025 with multiple diagnoses that included hemiplegia (paralysis that affects only one side of the body) and essential hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure lunch menu was followed for 29 of 32 residents when:1. Kitchen served cheesecake instead of apple pie as posted on the menu.2. Registered Dietitian (RD) was not made aware of menu substitution in a timely manner. This failure resulted in 29 residents receiving dessert substitution during lunch, on 1/14/26, without the approval of the RD. A review of the posted undated weekly menu titled Fall/Winter 2025-2026, Week 3 indicated for Wednesday, Lunch included black bean soup, mixed green salad, turkey and Swiss sandwich, pasta salad, lettuce, tomato, and pickle, apple pie, 2% milk, hot tea, and coffee. During a concurrent observation and interview on 1/14/26, at 11:45 a.m., in the Dining/Activity Room, both residents, Resident 2 and Resident 3, ate lunch without assistance. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure dietary needs for one of three sampled residents (Resident 1) were updated and care planned. Registered Dietitian (RD) and Dietary staff were made aware of Resident 1's food preference and requested copy of weekly menu and this information was not addressed in a timely manner. This failure had the potential for Resident 1 to lose weight due to decreased consumption and/or anger/depression when resident's dietary requests were not met. A review of Resident 1's admission Record, printed 1/14/26, indicated Resident 1 was admitted to the facility with diagnoses that included status post (s/p) joint replacement surgery, Type II diabetes mellitus (T2DM, high blood sugar), and depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly secure medications and sharp instruments when one treatment cart was left unlocked and unsupervised, in an area where residents could access it. This failure had the potential for accidental medication administration, ingestion or injury to residents residing in the facility. During an observation on 11/05/24, at 7:46 a.m., with Licensed Vocational Nurse 1 (LVN 1) in the hallway, a treatment cart containing topical medications, ointments, scissors, nail clippers, and other treatment supplies was observed unlocked. The treatment cart was situated in between six resident bedrooms and the activity/dining room, and multiple residents passed the treatment cart during this time. The cart remained unlocked while LVN 1 went in four separate resident bedrooms to administer medications, until 11:30 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared under safe and sanitary conditions when: 1. Dry food items were stored less than 6 inches above the floor. 2. Refrigerated and frozen food items were unlabeled, and undated. 3. Dry food items were past their use by date. 3. Raw pork was stored directly over ready to eat shrimp. 4. There was dark brownish matter inside the resident ice machine, above the ice bin. These failures had the potential to put residents at risk for food borne illness and cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could have resulted in infection or spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow appropriate infection control practice when reusable resident-care equipment was not cleaned/disinfected in between residents. This failure had the potential to cause resident infection via cross-contamination. During a concurrent observation and interview on 11/5/24, at 7:46 a.m., in the resident bedroom hallway with Licensed Vocational Nurse 1 (LVN 1), LVN 1 took the blood pressure machine out of the drawer, did not sanitize the cuff and stated it was the first blood pressure she took that day. LVN 1 obtained resident 84's blood pressure reading, laid the blood pressure machine/cuff on the cart, prepared Resident 84's medications, and administered them. [...]

Inspectors wroteBased on observation, interview and records review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 18 out of 18 sample selected residents (Resident 234, 22, 30, 8, 237, 236, 10, 235, 21, 27, 17, 134, 137, 11, 135, 136, 31 and 138) who were residing at the facility and receiving food from the facility's kitchen when: 1. Facility did not ensure food temperatures were checked before serving to all 18 residents (IJ). 2. Multiple Dietary staff did not wear hair nets and beard nets while working in the kitchen. 3. A Dietary staff did not wash hands upon entering the kitchen. 4. 24 plated foods were stored in the refrigerator without covers and three of three-gallon tub ice creams with no lids were stored in the freezer. 5. Ice Cream freezer had frost around the rim and inside the freezer. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain good personal hygiene for three of 22 sampled residents (Resident 30, Resident 234, and Resident 11). This failure resulted in Resident 30, Resident 234, and Resident 11's missed scheduled showers and a potential to cause low self-esteem and embarrassment to the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. maintain an accurate accountability sheet that documented the number of controlled substances (Diazepam tablets) that should be available for destruction and 2. provide pharmaceutical services including the provision of routine medications to meet the needs of one of seven (Resident 19) sampled Residents. These failures had the potential to cause diversion of controlled medication (illegal use of medication not intended by the provider) and adverse health outcomes related to incorrect medication administration.

Inspectors wroteBased on observations, interviews, and document reviews, the facility failed to ensure its medication error rate was less than 5% for two of seven sampled residents (Resident 22 and Resident 234) when the medication error rate was 16/67%. This failure had the potential for adverse health outcomes related to incorrect medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure the annual Minimum Data Set (MDS, an assessment tool used to guide resident care) was completed within the required timeframes for one of 22 sampled residents (Resident 21). Resident 21's annual MDS was not completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items). This deficient practice had the potential to result in Resident 21 not receiving the appropriate care and services needed based on the resident's current health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS, an assessment tool used to guide resident care) were completed and submitted within the required timeframes for three of 22 sampled residents (Resident 17, Resident 20, and Resident 21). Resident 17, Resident 20, and Resident 21's quarterly MDS' were not completed within 14 days of the Assessment Reference Date (ARD, a date set to establish a uniform look-back period for all the responses to MDS coding items) and were not submitted within 14 days from the completion of the MDS Assessments. These deficient practices had the potential to result in Resident17, Resident 20, and Resident 21 not receiving the appropriate care and services needed based on their current health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Discharge Assessment Minimum Data Set (MDS, an assessment tool used to guide resident care) were completed no later than 14 calendar days after the discharge date and submitted no later than 14 days after the MDS completion for four of 22 sampled residents (Resident 3, Resident 16, Resident 20, and Resident 23). This failure resulted in delayed completion and submission of Resident 3, Resident 16, Resident 20, and Resident 23's MDS Discharge Assessments.

Inspectors wroteBased on interview and record review the facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week when the facility did not have RN in all weekends since August/2023. This failure resulted in not following the CMS regulation and not having RNs to do the staff supervision, emergency coordinator, physician liaison, as well as direct resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated resident ' s preferences for one of four sampled residents (Resident 1). This failure had the potential to result in inadequate food intake, weight loss, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of nine sampled residents' (Resident 112, 107, 1, and 157) admission (an assessment within 14 calendar days after admission) or Annual Minimum Data Set (MDS, a comprehensive assessment of each residents' functional capabilities and helps nursing home staff identify health problems) assessments were completed when: 1. Resident 112's admission MDS assessment was not completed, 2 Resident 107's Annual MDS assessment was not completed, 3. Resident 1's MDS Section C (Cognitive Patterns) was not completed, and 4. Resident 157's admission MDS assessment was not completed. These failures had the potential for Residents 112, 107, 1, and 157 to not receive individualized plan of care based on their physical, mental, and emotional needs.

Inspectors wroteBased on interview and document review, the facility failed to follow its pneumonia vaccine policy and procedure for four of nine sampled residents (Resident 109, 110, 112, 113) when Residents 109, 110, 112, and 113 were not offered the pneumonia vaccination and their immunization records were not updated. This failure had the potential for vulnerable residents in the facility to become exposed to bacteria that causes serious infections in the lungs, ears, sinuses, brain/spinal cord tissue, and blood.

Inspectors wroteBased on observations, interviews, and document reviews, the facility failed to be free of medication error rate of five percent or greater for two medication errors observed out of 27 opportunities when gloves were not worn during the administration of a Lidocaine patch (medication used for pain) and eye drop medication administration policies and procedures were not followed. The medication error rate was calculated as followed: two divided by 27 then multiplied by 100, which was equal to 7.4 percent. This failure had the potential for the spread of infection and a decreased medication therapeutic effect for the affected residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label food safely when Refrigerator #1 (Ref #1) had two boxes of lactose free milk and one soy original milk with no labeled open dates and times. This deficient practice placed the residents at risk for food borne illnesses.

Inspectors wroteBased on interview and document review, for one of nine sampled residents (Resident 1), the facility failed to ensure a resident was monitored during the use of antibiotic (medication used to treat bacterial infections) when Resident 1 was prescribed amoxicillin (antibiotic medication) and was not monitored. This failure resulted in the potential for prolonged and unnecessary use of the antibiotic for Resident 1.

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop policies and procedures to address COVID-19 (an infectious disease spread by person to person through respiratory droplets) vaccinations for their nursing registry staff. This failure had the potential for registry staff to spread COVID-19 infection to the residents and the facility's regular staff.