Lake Pointe Health Care

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to ensure timely provider notification of critical laboratory (lab) values. This affected three (#53, #68, and #86) of four residents reviewed for laboratory services. The facility census was 85.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure staff followed the smoking policy and ensured safe resident smoking practices. This affected one (Resident #22) of one resident reviewed for smoking. The facility census was 91 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to maintain acceptable infection control practices during medication administration to prevent the spread of infection. This affected one resident (Resident #46) of three residents reviewed for medications. The facility census was 91 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure fall interventions were implemented per physician order. This affected one (#18) of three residents reviewed for falls. The facility census was 87.

Inspectors wroteBased on medical record review, review of an activity calendar, observation, and staff interview, the facility failed to ensure residents were provided with assistive devices per physician orders and the plan of care. This affected one (#18) of three residents reviewed for assistance with eating and drinking. The facility census was 87.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #33. This affected one resident of one (Resident #33) reviewed for dialysis. The facility census was 82.

Inspectors wroteTHIS DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THE ON-SITE INVESTIGATION. Based on observation, medical record review, staff interviews, review of a police report, review of a facility investigation, review of written statements, and review of facility corrective action documents, the facility failed to provide adequate supervision to prevent Resident #50, who had moderately impaired cognition, a diagnosis of vascular dementia with behavioral disturbances, and a previous incident of attempting to exit the facility, from leaving the facility unsupervised. This resulted in Immediate Jeopardy on 07/14/24 between approximately 3:00 P.M. and 5:44 P.M. [...]

Inspectors wroteBased on medical record review, review of controlled drug administration records, staff interview, and review of facility policy, the facility failed to ensure as-needed controlled medications were recorded on the Medication Administration Record (MAR) when administered. This affected three residents (Residents #07, #17, and #92) of three residents reviewed for controlled medications. The facility census was 91.

Inspectors wroteBased on observation, medical record review, review of a meal ticket, and staff interview, the facility failed to ensure residents were served food and drinks according to the menu and meal tickets. This effect one (#4) of four residents reviewed for provision of food and drinks. The facility census was 98.

Inspectors wroteBased on record review, observation and interviews, the facility failed to follow the physicians order to change oxygen tubing weekly on night shift and label with a date. This affected five residents (#17, #28, #43, #46, and #47) out of seven residents observed using oxygen. In addition, the facility failed to ensure a physicians order was in place for the use of oxygen for one resident (Resident #438) out of seven residents reviewed for oxygen therapy. The facility census was 95.

Inspectors wroteBased on record review and staff interview the facility failed to complete a care plan regarding pain. This affected one resident (#12) of six residents reviewed for pain control. The facility census was 95.

Inspectors wroteBased on record review and staff interview, the facility failed to complete quarterly care plan conferences for residents. This affected one resident (#80) out of two residents reviewed for care conferences. The facility census was 95.

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to assist residents in activities of daily living (ADL). This affected two residents (#18, #438) out of four residents reviewed for ADL's . The facility census was 95.

Inspectors wroteBased on record review and interview, the facility failed to ensure wound dressings were changed per physicians order for residents. This affected one resident (#438) of three residents reviewed with wound care orders. The facility census was 95.

Inspectors wroteBased on record review, observation, staff interview, and policy review the facility failed to store a resident's medication safely. This affected one resident (#80) out of three residents reviewed. The facility census was 95.

Inspectors wroteBased on record review, facility policy review, observations and staff interviews, the facility failed to maintain infections control protocol regarding a resident's indwelling catheter bag. This affected one (Resident #62) of four residents observed with indwelling catheter bags. In addition, the facility failed to implement a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. This had the ability to affect all 80 residents residing in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Resident #88 and/or the resident's representative were notified of the facility's policy for bed hold including the reserve bed payment. This finding affected one (Resident #88) of one resident reviewed for hospitalization.

Inspectors wroteBased on resident and staff interviews, medical record review and review of the facility policy, the facility failed to provide grooming for a resident unable to carry out Activities of Daily Living (ADL) independently. This affected one (Resident #56) of two reviewed for ADLs. The facility census was 80. Findings Included: Review of the medical record revealed Resident #56 was admitted on [DATE]. Diagnoses included transient cerebral ischemic attack, and very low level of personal hygiene. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed one person physical assist for dressing and personal hygiene. Observations on 06/03/19 and 06/04/19 revealed Resident #56 with long facial hairs on the chin and under the nose. Interview on 06/05/19 at 9:52 A.M. with Resident #56 reports, I would like for someone to help with my facial hair removal. [...]