Lake Pleasant Post Acute Rehabilitation Center

Inspectors wroteBased on closed record review, staff interviews, review of facility process and policy the facility failed to ensure that all transfer/discharge notifications were made for one resident (#130). The sample size was four. The deficient practice could lead to notifications and pertinent information regarding the discharge/transfer not being provided.

Inspectors wroteBased on observations, staff interviews, review of facility documentation and policies and procedures, the facility failed to ensure that food was prepared, stored, distributed and served in accordance with professional standards for food service safety. The deficient practice could result in food- borne illness. Findings Include: Regarding Kitchen Cleanliness-An initial kitchen observation was conducted on February 23, 2026 at 8:12 A.M. in conjunction with kitchen staff #86. During the initial observation it was observed that floor had several areas of dark matter that appeared to have accumulation in the corners of the tile floor. It was observed that a square, depressed area under the dish sink had black matter that appeared wet within its perimeter. Various pieces of solid debris were located in this area. Visible debris was observed on the floor under food preparation counters. [...]

Inspectors wroteBased on clinical record review, staff interviews, facility policy and the Resident Assessment Instrument (RAI) manual , the facility failed to ensure MDS assessment for 2 of 3 sampled residents (#21 and #100) were accurate. The deficient practice could result in assessment inaccurately reflects the resident's status.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#148) received care and treatment in accordance with professional standards of practice regarding intravenous antibiotic treatment. The sample size was 16. The deficient practice has the potential to cause the wound not to heal and increase the spread of infection.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review, the facility failed to ensure there was a physician order for oxygen use for one sampled resident (#12). This deficient practice could result in the resident receiving unnecessary oxygen or not receiving the correct oxygen flow rate needed.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to provide a dignified dining experience to Resident #62, Resident #149, Resident #47 and Resident #42. The facility census was 99.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The deficient practice could contribute to the spread of foodborne illness.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to provide evidence that monthly billing statements were issued to one resident (#62). The deficient practice could result in residents not being informed of the monthly payment deducted from their personal accounts.

Inspectors wroteBased on clinical record review, staff and resident interviews and policy and procedures, the facility failed to ensure that care and assistance were provided to one resident (#1) with a prosthesis that did not fit properly. The deficient practice could result in a decline in mobility and level of functioning, requiring more assistance and being more dependent.

Inspectors wroteBased on personnel record reviews, staff interviews and policies and procedures, the facility failed to ensure that one of 10 sampled employees (#80) had current evidence of freedom from infectious Tuberculosis (TB). The deficient practice could result in the potential of residents and employees being exposed to TB.

Inspectors wroteBased on clinical documentation, staff interviews, and facility policy and procedures, the facility failed to monitor and maintain acceptable parameters of nutrition for two residents (#12 and #36). The deficient practice could result in a physical and a mental decline in overall health.

Inspectors wroteBased on closed clinical record review, staff interviews, facility documentation and policy review and the State Agency database, the facility failed to ensure that an allegation of abuse for one resident (#44) was reported to the State Agency (SA) as required. The deficient practice could result in residents not protected from further abuse and allegation not investigated.

Inspectors wroteBased on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#44) was thoroughly investigated. The deficient practice could result in residents not protected from further abuse and appropriate corrective action not taken.

Inspectors wroteBased on observations; resident, resident representative, and staff interviews; facility documentation; and review of facility policies, the facility failed to ensure profession standards of care were maintained related to: a physician's order was not obtained before administering oxygen to one resident (#385) and the facility failed to ensure ordered care was provided related to a infection for one resident (#135). The deficient practices could result in resident's getting unsuitable treatment and for negative resident outcomes.

Inspectors wroteBased on resident, resident representative, and staff interviews and facility documentation, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. This deficient practice resulted in residents' needs not being met.

Inspectors wroteBased on clinical record review, staff interviews, review of facility documentation and policies, the facility failed to ensure accuracy of provider order for a psychotropic medication that was administered to one resident (#136). The deficient practice could result in adverse medication effects.

Inspectors wroteBased on review of the clinical records, staff interviews, and facility policies and procedures, the facility failed to notify the legal guardian for one resident (#52) with impaired cognitive status for consents for treatment, the facility failed to notify the legal guardian for one resident (#52) with impaired cognitive status for a change in condition. The deficient practice could result in other guardians not being notified.

Inspectors wroteBased on observations, resident, resident representative, and staff interviews, and facility documentation, the facility failed to ensure necessary services were provided to maintain personal hygiene for one resident (#41).

Inspectors wroteBased on resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that one sampled resident (#15) was assisted with making a vision appointment. The deficient practice could result in decreased vision abilities.

Inspectors wroteBased on review of clinical records, staff interviews, and facility policies and procedures, the facility provided a psychotropic medication for Bipolar disorder for one resident (#71) without a diagnosis of Bipolar disorder: