Lake Park Nursing and Rehabilitation Center

Inspectors wroteBased on record review, and staff, resident, and Physician interviews, the facility failed to ensure advance directive information was consistent throughout the medical record for 1 of 4 residents reviewed for advance directives (Resident #84).

Inspectors wroteBased on record review, observations, and staff and Nurse Practitioner interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 2 residents reviewed for respiratory care (Resident #60).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns voiced by residents during Resident Council meetings for 3 of 4 months reviewed (November 2025, December 2025, and January 2026). Review of the Resident Council meeting minutes for October 2025, November 2025, December 2025, and January 2026, revealed the following:a. The Resident Council minutes dated 10/08/25, revealed, under New Business, resident concerns regarding lack of available linen, towels, and washcloths.b. The Resident Council minutes dated 11/5/2025 revealed concerns regarding housekeeping staff not removing trash and failing to clean residents' bathrooms and bedrooms. There was no follow up information documented regarding the facility's response to address the concerns noted in the October 2025 meeting. c. [...]

Inspectors wroteBased on record review and staff, Nurse Practitioner, Orthopedic Nurse Practitioner, and Physician's interviews the facility failed to provide monitoring for skin breakdown under a leg immobilizer for 1 of 3 residents (Resident #1) reviewed for wound care. Resident #1 developed a stage 3 pressure ulcer to her right thigh which was found on 2/19/2025, and a pressure ulcer to the right ankle. On 3/18/25 the pressure ulcer to the right ankle was assessed as an unstageable pressure ulcer.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to protect resident privacy by leaving an unattended resident roster with personal health information (PHI) on top of a medication cart in the hallway and visible to the public. This was for 1 of 3 medication carts (700 Hall Medication Cart) reviewed for privacy and confidentiality. This deficient practice had the potential of effecting 22 residents on the 700 hall (Resident #98, #12, #96, #54, #82, #90, #97, #57, #33, #204, #88, #203, #55, #99, #91, #13, #83, #7, #20, #51, #35, and #60).

Inspectors wroteBased on record review, and interviews with residents and staff, the facility failed to provide an ongoing individual activity program per resident's preference (Residents #49 and #76) and an ongoing group activity program per Resident Council (Residents #1, #5, #77 and #88) when residents expressed a request to play more Resident-led bingo. This failure occurred for 6 of 6 sampled residents reviewed for individual and group activities.

Inspectors wroteBased on observations, record reviews and staff and resident interviews, the facility failed to ensure residents' toenails were trimmed and podiatry services were arranged for 3 of 4 residents (Resident #28, Resident #1 and Resident #63) reviewed for foot care.

Inspectors wroteBased on a breakfast meal test tray observation, minutes from Resident Council meetings, a Resident Council meeting, resident and staff interviews, the facility failed to provide food that was palatable and had an appetizing temperature for 8 of 8 residents reviewed for palatable foods (Resident #5, Resident #1, Resident #88, Resident # 77, Resident # 76, Resident #95, Resident #63, and Resident # 34).

Inspectors wroteBased on observations and staff interviews, the facility failed to dry metal pans before being stacked, clean 1 of 3 ice machines in 1 of 3 nourishment rooms (medical unit), and store dry goods off the floor. These failures had the potential to affect food served to residents.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to offer a bed bath for two days, provide nail care, and shave a resident dependent on staff for activities of daily living (ADL). This failure occurred for 1 of 4 sampled residents reviewed for ADL (Resident #63).

Inspectors wroteBased on observations, record review, interviews with a resident and staff, the facility failed to provide larger portions per physician order to a resident at risk for weight loss due to a history of weight loss (Resident #73).

Inspectors wroteBased on observations, interviews and record review, the facility failed to post daily nurse staffing data at the beginning of the shift for 1 of 4 days reviewed.

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the type of discharge on a Discharge Minimum Data Set (MDS) assessment for 1 of 4 sampled residents reviewed for discharge planning (Resident #102).

Inspectors wroteBased on record review, and resident, family member and staff interviews, the facility failed to provide residents with a summary of their baseline care plan within 48 hours of admission that included initial goals based on admission orders, physician orders, and a summary of services or treatments to be administered by the facility. This was for 4 of 4 residents reviewed for baseline care plan (Resident #203, Resident #33, Resident #88, and Resident #99).

Inspectors wroteBased on record review, staff interviews, and family interview the facility failed to provide supervision to prevent accidents for a resident with a known history of falls, when Resident #1 was left unattended in the common area and had an unwitnessed fall. This occurred for 1 of 1 resident reviewed for accidents and resulted in the resident going to the hospital to receive 7 stitches to his face (Resident #1).

Inspectors wroteBased on observations, record review, staff interviews, resident interview, and Physician interview the facility failed to administer scheduled pain medication after it was requested for a resident that was experiencing ten out of ten pain. This occurred for one of four residents reviewed for pain. (Resident #310) This failure resulted in Resident #310 experiencing her pain being off the charts and crying related to her pain.

Inspectors wroteBased on observations, record review, staff interviews, and resident interviews the facility failed to have sufficient nurse staffing to ensure residents received pain medication when needed. (Resident #310).

Inspectors wroteBased on observation, staff interviews and record reviews, the facility failed to remove expired medications in accordance with manufacturer's guidelines and failed to date an opened eye medication for 4 of 6 medications carts observed during medication storage checks (200 hall, 400 hall, 600 hall, and 700 hall).

Inspectors wroteBased on observations, record review, staff interviews, Physician interview, and Family interviews the facility failed to communicate and provide information in a language the resident could understand for 1 of 1 resident whose primary language was Spanish (Resident #29).

Inspectors wroteBased on observations, record review, resident interviews and staff interviews the facility failed to provide nail care for 2 of 6 sampled residents (#5 and #48) reviewed for activities of daily living (ADL). 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included anemia, chronic kidney disease, dementia, and seizure disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene; total dependence on locomotion and bathing; supervision with eating. A revised care plan dated 12/23/22 revealed Resident #5 required assistance with ADLs to maintain or achieve the highest level of functioning by providing total care for personal hygiene/ grooming (face, skin, hands, nails, and perineum). [...]

Inspectors wroteBased on observations, staff interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions for Activities of Daily Living Care Provided for Dependent Residents, which were put into place during the complaint investigation survey of 2/21/22, and on the current recertification and complaint investigation survey of 5/5/23. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program.

Inspectors wroteBased on record review, resident interviews, and staff interviews, the facility failed to resolve group grievances that were brought to resident council meetings for 5 consecutive months. Review of Resident Council Minutes from 12/7/22, 1/4/23, 2/22/23, 3/1/23, and 4/5/23 was completed. Each month's Resident Council meeting minutes had a section entitled New Business, and cold foods was listed under this section for 12/7/22, 2/22/23, and 4/5/23. Resident council minutes for 1/4/23 and 3/1/23 did not identify a resolution to complaints of cold foods from previous resident council minutes (12/7/22, 2/22/23 and 4/5/23). During an interview on 5/2/23 at 4:22 PM the Activities Director indicated her standard practice for submitting grievances voiced in resident council meetings was to document the grievances on the meeting minutes form and provide the Administrator the form. [...]