Lake Placid Health and Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility failed to inform the resident's Health Care Surrogate (HCS) of medication changes, prior to implementing the changes for one resident (#1) of three residents sampled for notification of changes.

Inspectors wroteBased on interviews and record review, the facility failed to identify and assess a change in condition in a timely manner for one resident (#1) of three residents sampled. Findings Included: Review of Resident #1's admission record revealed an initial admission date of 07/01/2019 and a discharge date of 07/28/2025. Resident #1 was admitted to the facility with diagnosis to include multiple sclerosis (07/01/2019), adult failure to thrive (07/01/2019), personal history of urinary (tract) infections (07/01/2019), cystic disease of liver (11/10/2021), dysphagia, oropharyngeal phase (01/17/2024), and abnormal weight loss (12/06/2023). The review showed resident #1 had a responsible Party (RP) who was also the POA (Power of Attorney) and Emergency contact #1. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure dietary allergies and dietary preferences were honored for four residents (#146, #37, #101, #11) out of five residents reviewed for nutritional services. These failures resulted in emotional harm to one resident (#146) resulting in a discharge against medical advice (AMA), and potential harm due to food allergies to two residents (#37, #11) when the wrong dietary trays were served on multiple occasions.

Inspectors wroteBased on interviews and record review, the facility failed to promptly notify the resident and resident representative (RR) of a change in room or roommate assignment for three (#146, #172 and #173) of three residents sampled.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure grievances were being addressed for five out of six months of resident council meetings and for three (#101, #106, #172) out of three residents sampled for grievances.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the transfer or discharge was documented in the resident's medical record and a notice was given before the transfer or discharge for two residents (#124 and #172) out of two residents reviewed for transfer/discharge process.

Inspectors wroteBased on observations, interviews and record review the facility did not ensure level I and level II Preadmission Screening and Resident Review (PASARR) were accurate for 12 ( #1, 2, 8, 9, 15, 35, 55, 65, 76, 83, 118, and 172) out of 14 Residents sampled. Findings Included: Review of Resident 83's admission record revealed and admission date of 08/28/2024. Resident #83 was admitted to the facility with diagnosis to include Other Bipolar Disorder, Unspecified Mood [Affective] Disorder, Opioid Dependence, Uncomplicated, Bipolar Disorder, Current Episode Mixed, Moderate, And Generalized Anxiety Disorder. Review of Resident #83's PASARR dated 07/31/2024, revealed anxiety disorder was not marked. Questions 1-7 were all marked no. Section IV. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility did not follow professional standards for food service safety in the kitchen as evidenced by: a) dietary staff were not competent in the operation of the dish machine; b) the dish machine and refrigerator temperature logs had missed entries; c) hand hygiene and proper glove use was not performed; d) dietary staff's personal items were stored inappropriately; and e) resident's food items and beverages were not labeled and dated in the nourishment rooms.

Inspectors wroteBased on observations and interviews, the facility did not ensure infection control practices were followed as evidenced by: a) hazardous chemicals accessible in resident dining areas; b) improper hand hygiene by residents and staff during dining and medication administration; and c) improper personal hygiene practices related to personal cloth.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain a safe environment for residents related to 1) an unsecured steam table in the North Wing Dining Room; 2) No resident emergency call cords in two of two restrooms in the main hallway; 3) unsecured chemicals on two units (North Wing and Happy Trails); and 4) failure to provide one-to-one supervision for one resident (#65) out of one resident sampled for supervision.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and four errors were identified for 3 (#30, #94, and #97) of six residents observed. These errors constituted a 12.00% medication error rate.

Inspectors wroteBased on observations, interviews, and record review the facility 1) failed to maintain the storage of medications in four of four sampled medication carts (West Front, [NAME] Back, 200-hall and Happy Trails) without expired, undated and loose medications, 2) failed to ensure the locked narcotic boxes were unremovable for two (East and West) of two sampled medication refrigerators, 3) failed to ensure two of two sampled rescue carts (100 & 400 halls) which contained medication for low blood sugar were locked while unattended and not in use, and 4) failed to ensure medications were not stored at bedside in two resident rooms (309 and 406) observed during survey.

Inspectors wroteBased on observation, record review, interviews, and review of the Plan of Correction, the facility failed to ensure it had a functioning Quality Assurance Committee. The facility was actively involved in the creation, implementation, and monitoring of the plan of correction for deficient practice identified during an annual survey on 07/21/2025 to 07/24/2025 and was cited at F628. During the revisit on 09/23/2025 through 09/25/2025, the facility was recited at F628 related to discharge process. The facility had developed a Plan of Correction with a completion date 08/22/2025. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure dignity was maintained for residents during meals on one unit (East Wing) out of three units in the facility.

Inspectors wroteBased on observations, interviews and record review the facility failed to honor 1 (Resident #83) choice to transfer to another facility out of 5 residents sampled. Findings Included: During an interview on 07/21/2025 at 11:12 a.m., Resident #83 stated she wanted to go to a another facility. She said, I talked to them about this and nothing happens. They don't care and they act like they don't hear you. Review of Resident 83's admission record revealed an admission date of 08/28/2024. Resident #83 was admitted to the facility with diagnoses to include unspecified protein-calorie malnutrition, other bipolar disorder, unspecified mood [affective] disorder, opioid dependence, uncomplicated, bipolar disorder, current episode mixed, moderate, and generalized anxiety disorder. Review of Resident #83's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C. [...]

Inspectors wroteBased on interviews and record review the facility did not provide preparation and orientation for discharge and complete a discharge summary for one resident (#124) out of two reviewed for discharge.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure Activities of Daily Living (ADL)'s were completed for three residents (#80, #83, and #11) related to matted hair, untrimmed fingernails, haircuts, and showers out of three residents reviewed. Findings Included: During an observation on 07/21/2025 at 11:27 a.m., Resident #80 was observed lying in bed dressed in a hospital gown. Resident #80's hair was observed unkept and matted. Resident #80 stated “I would like my hair brushed; I have knot in my hair.” Resident #80's nails were observed to be yellow, overgrown with black debris underneath them. Resident #80 stated “If I had scissors, I could cut them, I don’t like them being this long. You would be a miracle worker if you could get my hair fixed.” Review of Resident #80's admission record revealed an admission date of 11/27/2023. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure medication recommendations from the pharmacy consultant were reviewed and addressed by the medical provider for one (#8) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a functioning grievance process for three (Resident #1, #2, and #9) of three residents sampled for grievance process.

Inspectors wroteBased on record review and interviews, the facility failed to convey personal funds deposited with the facility within 30 days of discharge with a final accounting of the funds to the resident for one (Resident #2) of one resident reviewed for personal funds of thirteen sampled residents.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy, the facility failed to 1.) complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for eight (Residents #19, #12, #48, #101, #50, #47, #74, and #78); and 2.) ensure the accuracy of a PASARR Level I for two (Residents #24 and #223) of ten residents admitted with mental health diagnoses sampled for PASARR.

Inspectors wroteBased on record review, observations, interviews, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to ensure the development and/or implementation of comprehensive care plans was completed for five (Resident #5, #12, #41, #81, and #82) of 44 sampled residents.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure three (Residents #40, #13 and #88) of six residents reviewed for vaccine administration were offered and administered Pneumococcal vaccinations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignified assistance during dining for two (Residents #11 and #72) of 44 residents sampled.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure timely completion of a comprehensive assessment for one (Resident #223) of 44 sampled residents.

Inspectors wroteBased on interview, record review and, policy review, the facility failed to ensure there was ongoing communication and collaboration with the dialysis facility for one (Resident #59) of one resident reviewed for dialysis care and services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate of less than five percent. A total of 32 medication administration opportunities were observed with 2 errors, resulting in a medication administration error rate of 6.25%.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement an effective Infection Control and Prevention program by 1.) failing to ensure hand hygiene was conducted during a dressing change for an intravenous (IV) line for one (Resident #224) and during medication administration for one (Resident #123), 2.) failed to ensure proper set up of a sterile field during a dressing change for an IV line for one (Resident #224), 3.) failed to ensure proper disinfection of point-of-care devices for one (Resident #123), and 4.) failed to ensure isolation precautions were followed for one (Resident #224) of forty four sampled residents.

Inspectors wroteBased on record review, interviews, observation, and policy review the facility did not ensure a care plan was developed for wandering for one (#65) of 40 sampled residents, and the facility failed to implement the plan of care for seizure precautions for one (#49) of 40 sampled residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly assess the activity needs to ensure an individualized and meaningful activity program was developed for two (#49, #5) of three residents sampled for activities.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure respiratory equipment was stored in accordance with professional standards of practice for one (Resident #195) of one resident sampled out of 12 residents in the facility receiving respiratory care and treatment.