Lake Port Square Health Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 4 (Resident #4, #6, #8 and, #15) of 9 residents reviewed. Based on observation, interview and record review the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 4 (Resident #4, #6, #8 and #15) of 9 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments were updated following documentation of a new diagnosis for 2 Residents (Resident #4 and #9) out of 5 residents sampled for preadmission screening and resident reviews (PASARR).

Inspectors wroteBased on observation, interview and record review the facility failed to administer correct dosage amount of medication to 1 (Resident #9) of 6 residents reviewed for medication administration and failed to provide intravenous device care as per nursing standards for 1 (Resident#15) of 2 residents reviewed for intravenous infusions.

Inspectors wroteBased on observation, interview and record review the facility failed to provide nutritional supplements as order for 1 (Resident #12) of 6 residents reviewed for nutritional services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the oxygen delivery rate was specified for 1 resident, Resident #11, and failed to ensure nebulizer equipment was properly stored for 1 resident, Resident #85, of 3 residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview and record review the facility failed to follow standards of medication storage for 2 out of 6 halls reviewed for unattended medication.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was stored in a safe manner in the main kitchen and in 1 of 2 nourishment rooms.

Inspectors wroteBased on observation and interview the facility failed to ensure garbage and refuse was disposed of properly.

Inspectors wroteBased on interview and record review the facility failed to document therapy sessions for 1 (Resident #38) out of 2 residents reviewed for rehabilitation services.

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1(Resident #20) of 3 residents reviewed for nutrition.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop a comprehensive care plan for 1 (Resident #26) of 5 residents reviewed for medication administration, and 2 (Resident #265 and Resident #266) of 4 residents reviewed for respiratory services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 1 (Resident #265) of 4 residents reviewed for respiratory services.

Inspectors wrote2) During an observation on 2/10/2025 at 9:18 AM, Resident #43 was sitting in his room in a chair. There was one bottle of Latanoprost 0.005% eye drops on top of the bedside table (Photographic evidence obtained). During an interview on 2/10/2025 at 9:18 AM, Resident #43 stated, Someone brought it [eye drops] one night and left it behind. I think it needs to be thrown out. During an interview on 2/13/2025 at 9:10 AM, the Director of Nursing stated, [Resident #43's name] is not able to self-administer medications and medication should not be left unattended in the residents room. Review of the facility policy and procedures titled Medication Labeling and Storage with the last review date of 12/2/2024 showed it read, Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was safely and properly stored, labeled, or discarded in the areas of the kitchen walk-in cooler, and failed to ensure all areas were cleaned and free of debris.

Inspectors wroteBased on record reviews and interviews, the facility failed to accurately document notifications of medication parameters for 3 (Resident #26, #27, and #163) of 6 residents reviewed for medication administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to help prevent the spread and transmission of communicable diseases and follow infection control standards of practice for hand hygiene during 1 of 5 medication administration observations, 2 (Resident #265 and #266) of 10 residents reviewed for respiratory care equipment, 2 (Resident #20 and #167) of 4 residents reviewed for enhanced barrier precautions and 1(Resident #15) of 1 resident reviewed for transmission based precautions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure central venous catheter dressing was changed in accordance with professional standards of practice for 2 of 2 residents with central venous catheters, Residents #3 and #4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen was administered as prescribed by the physician for 2 of 4 residents reviewed for oxygen administration (Residents #20 and #64).

Inspectors wroteBased on record review and interview, the facility failed to ensure the consulting pharmacist reported any irregularities to the attending physician and director of nursing, and these reports were acted upon for 3 of 5 residents reviewed for unnecessary medications (Residents #1, #36 and #59).

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for 1 of 3 residents reviewed for communication/sensory services (Resident #23), 1 of 1 resident reviewed for hospice services (Resident #15), 2 of 6 residents reviewed for nutrition (Residents #6 and #21), and 1 of 4 residents reviewed for respiratory care (Resident #35).

Inspectors wroteBased on record review and interview, the facility failed to develop a person-centered care plan for 1 of 4 residents reviewed for oxygen therapy (Resident #35) and failed to implement weight orders for 1 of 6 residents reviewed for nutrition (Resident #48).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to treat pressure ulcers for 1 of 3 residents reviewed for skin conditions (Resident #54).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was as free of accident hazards as is possible and each resident received adequate supervision while being transferred utilizing a mechanical lift for 1 of 2 residents reviewed for accidents (Resident #17).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 2 of 4 medication carts and failed to ensure the medication were secured in 1 of 2 units.

Inspectors wroteBased on record review and interview, the facility failed to provide laboratory services for the monitoring of Valproic Acid levels for 3 of 7 residents reviewed for mood and behavior (Residents #6, #17, and #25).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment of pressure ulcers was accurately documented for 1 of 3 residents reviewed for skin conditions (Resident #54).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration, during wound care for 1 of 3 residents reviewed for wound care (Resident #54), and during providing direct care to Resident #64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted on a daily basis.