Lake Ridge Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's authority by extending the resident's representative the right to make decisions on behalf of the resident beyond those which were previously delegated by the residents, within the resident's advance directives (AD, a legal document in which a individual person specifies what actions should be taken for their health care and/or finances in the event they were no longer are able to make decisions for themselves because of illness or incapacity), for 1 of 3 residents (Resident 49) reviewed for resident rights with acceptance of a binding arbitration agreement (an alternative means of settling disputes without a jury by trial). This failure placed the resident at risk for violation of their rights as a resident who had made their health care and financial wishes known.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented interventions to prevent resident to resident altercations involving 4 of 7 Residents (12, 24, 40 and 39) reviewed for abuse. This failed practice placed residents at risk for physical harm, mental anguish, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] were not inappropriately placed in nursing homes for long term care) were accurately completed for 3 of 5 residents (Resident's 24, 2, and 47) reviewed for accuracy of PASARR assessments. Additionally, no referrals had been requested for a PASARR Level II (a comprehensive evaluation by the appropriate state-designated authority) which is required if the PASARR Level l has indicators of mental illness. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure identification and evaluation of accident (any unexpected or unintentional incident, which results or may result in injury or illness to a resident) risk/hazards (elements of a residents environment that have the potential to cause injury or illness) regarding residents spilling hot liquids on themselves, nor implementation of an individualized, resident-centered care plan to reduce the risk/hazards related to the spilling of hot liquids for 2 of 3 residents (Resident 48 and 51) reviewed for accident/hazards. This failure placed residents at an increased risk for avoidable accidents, significant injury, and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to obtain registry verification to ensure staff met competency evaluation requirements for 2 of 3 Nursing Assistants (NA, Staff M and N) reviewed for staff qualifications. This failure placed residents at risk for abuse/neglect and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 5 residents (Resident 16) had documentation in their record to indicate the resident or their representative was provided education on the influenza vaccine reviewed for vaccinations. This failure placed residents and their representatives at risk for not having the knowledge to make an informed decision on whether to receive an influenza vaccination or to decline it.

Inspectors wroteBased on interview and record review, the facility failed to ensure orders given by a urologist [a doctor who specializes in the urinary system (the body's drainage system for filtering waste and excess fluid to produce and expel urine) and male reproductive system] were completed and reviewed, in a manner that met professional standards of practice, for 1 of 3 residents (Resident 1) reviewed for change in condition related to the urinary system. Resident 1 experienced harm when they were hospitalized for sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection causing widespread inflammation and injury to organs) related to an untreated urinary tract infection [(UTI) an infection in any part of the urinary system--the kidneys, ureters, bladder and urethra].

Inspectors wroteBased on interview and record review, the facility failed to ensure the Resident Representative (RR) and physician were notified of multiple medication refusals that resulted in a change in condition for 1 of 2 residents (Resident 1) reviewed for change in condition. This deficient practice placed residents at risk of a potential delay in medical treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1) thoroughly evaluate and monitor the significant changes in a resident's respiratory condition and increased sedation from medications given for 1 of 3 residents (Resident 1) reviewed for change of condition; 2) accurately assess and notify the provider timely of wound changes for prompt medical evaluation for 1 of 3 residents (Resident 11) reviewed for skin conditions; 3) follow through with specialized services for 2 of 2 residents (Resident 34 and 57) reviewed for quality of care. This failed practice placed residents at risk of not receiving the care and services they needed to prevent a decline in their health and/or mobility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the supervised fall risk residents received adequate supervision of one staff assistance in the dining room, and proper use of fall prevention devices for 1 of 5 residents (Resident 218) reviewed for falls. Resident 218 experienced harm when they fell forward out of their wheelchair when staff forgot to place the drop-down seat into the reclining position after transferring the resident to their wheelchair and sustained an injury to their left forehead that required hospital intervention for control of bleeding and stitches.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents at risk for weight loss were reviewed for of 1 of 5 sampled residents (Resident 1) reviewed for nutrition. Resident 1 experienced harm as they had a 18.67% significant, unplanned, weight loss from 03/13/2025 to 04/22/2025 (40 days) and was found to have low protein levels and skin issues. This placed residents at risk for unplanned weight changes, health complications and nutritional decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to review and validate the Preadmission Screening and Resident Reviews (PASARR, an assessment to ensure individuals with Serious Mental Illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were accurate on admission for 3 of 5 residents (Residents 57, 24, and 45) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an Omnibus Budget Reconciliation Act (OBRA) registry (a registry that identified, prior to employment, if a Nursing Assistant (NA) was eligible to work in a skilled nursing facility) verification to show that an individual met competency evaluation requirements and had no disqualifying findings for 5 of 5 NAs (Staff AA, BB, CC, O, and S) reviewed for staff qualification and background review. This failed practice placed residents at risk of unmet care needs, abuse, neglect, and misappropriation. Findings Included . Review of the policy titled Abuse Prohibition dated 10/24/2022, showed the facility would screen potential employees for a history of abuse, neglect, and mistreatment of residents by obtaining information from past employees and checking with the appropriate licensing boards and registries. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable and sanitary environment was maintained for 5 of 8 resident rooms (Rooms 6, 43, 41, 35 and 11) and 2 of 3 shower rooms (A hallway and C hallway), reviewed for environment. This failure placed the residents at risk for potential accidents and not feeling safe/secure with their environment.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate a fall, for one of five sampled residents (Resident 218), reviewed for falls. The failure to complete a thorough investigation placed the residents at risk for potential negative health outcomes. Findings Including . <Resident 218> Review of the medical record showed Resident 218 was admitted to the facility on [DATE] with diagnoses to include dementia, muscle weakness, lack of coordination and repeated falls. The comprehensive assessment dated [DATE] showed Resident 218's cognition was severely impaired and was dependent on staff for activities of daily living (ADLs). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was admitted with a urinary catheter (a tube which drains urine from the bladder into a collection bag), received a referral to a urologist to determine function and continued use of a urinary catheter for 1 of 3 residents (Resident 1) reviewed for extended urinary catheter use. This placed the resident at risk for continued decline in urinary function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure continuous oxygen delivery was provided according to physician orders, monitored respiratory status, and the maintaining of respiratory equipment for 2 of 2 residents (Residents 1 and 53), reviewed for respiratory status. This failed practice placed residents at risk of unmet needs, discomfort, and secondary medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 6 residents (Residents 51 and 57) were free of unnecessary drugs due to lack of monitoring, timely administration, and care planning of high-risk medications. This failed practice placed residents at risk of receiving medications incorrectly, subtherapeutic (relating to drug dosages administered at too low a level to produce a therapeutic effect) treatment, and adverse side effects.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide appetizing and palatable meals for 3 of 3 residents (Resident 24, 1 and 36) reviewed for the dining experience. These failures resulted in residents expressing dissatisfaction with the food and placed residents at risk for inadequate nutritional intake and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from physical abuse by staff for 1 of 5 residents (Resident 1) reviewed for abuse. This deficient practice placed residents at risk for further abuse and potential injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a compromised resident who experienced a decline in condition with multiple falls and injury was seen timely by the physician when returned from a hospital stay for 1 of 3 residents (Resident 2) reviewed for change in condition. This deficient practice placed the resident at risk for further complications and decline in health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed safe supervision and handling of two trained staff for mechanical lift transfers for 1 of 3 sample residents (Resident 1), reviewed for mechanical lift transfers. Resident 1 experienced harm when they fell out of the mechanical lift sling while being transferred from their wheelchair to their bed with only one staff person assisting and sustained a laceration to the right side of their head that required hospital evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from physical abuse by staff for 1 of 3 residents (Resident 1) reviewed for abuse. This deficient practice placed residents at risk for further abuse and potential injuries.

Inspectors wroteBased on interviews and record review the facility failed to complete a performance review at least once every 12 months as required, for 5 of 5 Nursing Assistants (NAs) (Staff R, T, U, V, and W) reviewed for performance reviews. The failure to complete annual performance reviews placed residents at risk for unmet care needs from potentially unqualified staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions (EBPs, an approach to the use of personal protective equipment (PPE) to reduce transmission of Multidrug-Resistant Organisms (MDROs) between residents in skilled nursing facilities) and hand hygiene in the dining area were implemented for 6 of 6 staff members (Staff J, N, M, Q, JJ, and KK) reviewed for infection control practices. These failures placed all residents at risk for exposure, transmission of MDRO's, and serious medical complications.

Inspectors wroteBased on interview and record review, the facility failed to honor the resident's authority to exercise their right to not designate a representative to act on their behalf for 1 of 1 resident (Resident 16) reviewed for resident rights. This failure placed the resident at risk for violation of their rights as a resident to make their own health care and financial decisions.

Inspectors wroteBased on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage [(NOMNC) a notice that indicates when your care is set to end from a skilled nursing facility] as required for 1 of 3 residents (Resident 37) reviewed for beneficiary notification. Additionally, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice [(SNFABN) a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare; beneficiaries may choose to continue services but may be financially liable] for 2 of 3 residents (Residents 37 and 162) reviewed for SNFABN requirements. These failures placed the residents at risk for the inability to make informed financial and care decisions related to their continued stay.

Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary and homelike environment for 1 of 3 hallways (Hall C), 1 of 1 shower room (Hall C shower room), and 3 of 9 resident rooms (rooms [ROOM NUMBER]) reviewed for environment. Hall C smelled of urine, Hall C shower room was dimly lit, the ceiling fan was coated with lint, and the walls were missing tile that left exposed concrete. The resident rooms smelled of urine and had furniture/walls in disrepair. These failures placed the residents at risk for unpleasant living conditions, exposure to foul odors, and diminished self-worth.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an allegation of abuse/neglect was reported to the State Agency in a timely manner as required for 2 of 4 residents (Resident 38 and 5) reviewed for abuse/neglect. Failure to report the allegation physical and verbal abuse to the State Agency placed the residents at risk for unidentified and ongoing abuse/neglect.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes) for 2 of 4 residents (Residents 2 and 59) reviewed for transfer/discharge notice requirements. This failure placed the residents at risk for diminished protection, lack of access to an advocate that could inform them of their options and rights, and to ensure the resident advocacy agency was aware of the facility practices and activities related to a transfer or discharge. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 2 of 4 residents (Residents 16 and 38) reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review [(PASARR) - a federally required form that is used to help ensure individuals are not inappropriately placed in nursing homes for long term care] was accurate for 2 of 7 residents (Residents 16 and 52) reviewed for PASARR accuracy. This failed practice placed the residents at risk of not receiving specialized mental health services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure residents dependent on staff received consistent oral care for 1 of 3 residents (Resident 2) reviewed for activities of daily living (ADL). The failure to receive adequate oral hygiene according to the resident' Physician orders and care plan placed the residents at risk for unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement resident preferences for outdoor activities for 5 of 6 residents (Residents 56, 7, 13, 14, and 25) reviewed for activities. This failure placed residents at risk of frustration, boredom, and meaningful enjoyment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to prevent a potential reduction in range of motion for 2 of 3 residents (Residents 2 and 15) reviewed for range of motion and/or use of splints. This failure placed the residents at risk for decreased mobility and loss of independence.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate treatment and services related to enteral (tube) feeding ([TF], the delivery of nutrients through a tube directly into the stomach) for 1 of 2 resident's (Resident 52) reviewed for TF. The use of inappropriate connections to the percutaneous endoscopic gastrostomy (PEG) tube, placed the resident at risk for contamination and loss of caloric intake due to fluid leakage between the PEG tube and the tube feeding spike set (a device that connects the PEG tube to the formula feeding bag or bottle).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure continuous supply of oxygen was provided for 1 of 2 residents (Resident 56), reviewed for oxygen. This failure placed the resident at risk for respiratory distress, discomfort, and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure clinical records were complete and accurate for 3 of 3 residents (Residents 24, 2, and 49), reviewed for foot care. This failure placed residents at risk for medical complications and unmet care needs.