Lake Village Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information, for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS. The facility failed to submit staffing data to CMS for FY Quarter 1 2026 (October 1 - December 31). This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure all food items in the facility's kitchen were dated and discarded prior to their use-by date and were properly sealed. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 kitchen reviewed for environmental conditions. The facility failed to provide an effective pest control program treat the kitchen for cockroaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the residents' environment remained free of hazards as was possible for one of eighteen residents (Resident #55) reviewed for accident hazard. The facility failed to ensure there were no unattended container of germicidal wipes (substance that destroys germs and microorganism) on a table at the lobby, where Resident #55 was on 05/03/2026. This failure could place residents at risk of having an environment that was not free from exposure toxic chemicals.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for two of four residents (Resident #43 and Resident #91) reviewed for incontinent care. 1. The facility failed to ensure that CNA F did not use the wipes that she used to clean Resident #43's inguinal area (lower portion of the abdomen) to clean the perineal area (area between the legs) on 05/04/2026.2. The facility failed to ensure that CNA E did not place Resident #91's catheter bag on top of the resident's bed rendering the catheter to be not below the bladder while the resident's linen was being changed on 05/03/2026. These failures could place the residents at risk for urinary tract infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of ten residents (Resident #91) reviewed for respiratory care. The facility failed to ensure Resident #91's nasal cannula was stored properly when not in use on 05/03/2026. This failure could place residents at risk of respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of twenty residents (Residents #8 and Resident #34) reviewed for medication storage. 1. The facility failed to ensure that Resident #8 did not have a pain reliever gel inside her room on 05/03/2026. 2. The facility failed to ensure that Resident #34 did not have a tube of hydrocortisone cream (used to treat inflammation and itching) inside her room on 05/03/2026. These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of twenty residents (Resident #43 and Resident #91) reviewed for infection control. 1. The facility failed to ensure CNA F performed hand hygiene during Resident #43's incontinent care on 05/04/2026. 2. The facility failed to ensure CNA E did not put Resident #91's catheter bag on top of the resident's bed on 05/03/2026. 3. The facility failed to ensure LVN B and CNA E wore gowns when they changed Resident #91's linen, who had a catheter on 05/03/2026. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on interview, and record review, the facility failed to make sure every resident had full visual privacy for 1 of 4 residents (Resident #1) reviewed for dignity. The facility failed to ensure Resident #1 had full visual privacy and dignity by leaving Resident #1 lying in bed dressed only in a shirt and brief without a bed sheet, blanket, curtains, or a closed door from 2:19 AM to 4:43 AM. This was determined to be past non-compliance from 11/04/2025 to 11/5/2025 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of emotional or psychosocial harm by not receiving appropriate measures for privacy and dignity.

Inspectors wroteBased on interview, and record review, the facility failed to administer medications according to physician's orders for 1 of 4 residents (Resident #1) reviewed for medications. The facility failed to input a physician's order on the day that the order was received to ensure Resident #1 received Hydromorphone 4mg/ml MG every 4 hours instead of every 6 hours as previously scheduled. This was determined to be past non-compliance from 11/04/2025 to 11/5/2025 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of harm by not receiving their scheduled medication in a timely manner.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASARR evaluation report into the resident's assessment, care planning, and transitions of care for 1 (Resident #1) of 3 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for nursing facility specialized services in the long-term care online portal within 20 business days after the annual interdisciplinary team meeting on 03/04/2025. Resident #1 did not receive a repositioning wedge as recommended on the PASRR Comprehensive Service Plan. This failure could place residents at risk of not receiving individualized care and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of five residents observed for infection control. The facility failed to ensure that LVN B washed her hands or used hand sanitizer while administering medication to Resident #2 on 09/16/2025. This failure could place the residents at risk of cross-contamination and the development of infections.

Inspectors wroteBased observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (Residents #35, #36, #49, #168, #169, and #171) of twenty residents reviewed for Infection Control. 1. The facility failed to ensure CNA D and CNA E changed their gloves and performed hand hygiene while providing incontinent care to Resident #35 on 03/04/2025. 2. The facility failed to ensure LVN J sanitized the blood pressure cuff and the pulse oximeter while administering medications and checking the vital signs of Residents #36, #49, #168, #169, and #171 on 03/05/2025. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #45) of twenty residents reviewed for Dignity. The facility failed to ensure CNA F did not stand behind Resident #45 while assisting the resident to eat during lunchtime on 03/04/2025. This failure placed residents at risk of not having their right to a dignified existence maintained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure confidential and personal medical records for one (Residents #8) of twenty residents reviewed for Privacy and Confidentiality. The facility failed to ensure LVN G closed, locked, or minimized her laptop's monitor while administering medication to Resident #8 on 03/04/2025. This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #62) of eight residents reviewed for Care Plans. The facility failed to ensure Resident #62's care plan, dated 02/23/2025, included her CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) usage. This failure could place the residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #62) of twelve residents reviewed for Respiratory Care. The facility failed to ensure Resident #62 had an order for her CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) on 03/04/2025. This failure could place residents at risk for not having their respiratory needs met.

Inspectors wroteBased observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #36) of five residents reviewed for Pharmaceutical Services. The facility failed to ensure LVN J disposed of Resident #36's Tramadol properly on 03/05/2025. This failure could place residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for one cart (nurse's cart) of seven carts observed. The facility failed to ensure that LVN G locked her nurse's cart while passing medication at hall 300 on 03/04/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 2 (Rooms 303b, 307 b) of 6 resident rooms and all hallway handrails in the facility reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms # 303b, and 307 b were thoroughly cleaned and sanitized. The facility failed to ensure that the facility hallway handrails were cleaned. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure the ice scoop, ice scoop holder, and ice machine in the facility's dining area was cleaned. This failure could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 facility, reviewed for infection control. The facility DON (Infection Preventionist) failed to ensure: Residents who had the flu had appropriate signage on their door and PPE for use outside their door. Facility staff were utilizing appropriate PPE when caring for residents in isolation rooms. Facility staff notified the families of flu negative roommates that they were at risk of being infected with the flu. Flu negative residents were cohorted in the same room as flu positive residents. Flu negative roommates were offered the prophylactic treatment for the flu. An IJ was identified on 01/24/24. [...]

Inspectors wroteBased interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, reviewed for RN coverage. The facility failed to ensure the facility maintained the required RN coverage for 14 days between August - September 2023. This failure placed residents at risk of receiving higher levels of patient care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #228, Resident #7, and Resident #39) of twelve residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #228, #7, and #39's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 6 (Resident #5, #19, #30, #33, 43, and #51) of 20 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #5, #19, #30, #33, 43, and #51's rooms were cleaned, sanitized, and maintained. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.

Inspectors wroteBased on interviews, and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #51) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #51 received showers consistently. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Resident #51 Record review of Resident #51's face sheet dated 01/26/24 reflected an [AGE] year-old male who was originally admitted to the facility on [DATE]. Relevant diagnosis included need for assistance for personal care, history of falls, and right artificial hip. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated. The facility failed to ensure food in the freezer was not exposed from air-borne contaminants. The facility failed to ensure the ice machine, located in the facility's kitchen, was thoroughly cleaned. The facility failed to ensure the trash can in the kitchen area was covered. The facility failed to ensure the tea dispenser was covered after being prepared. The facility failed to ensure the ice chest located in the dining area was clean and sanitized. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #228) of 5 residents reviewed for dignity. The facility failed to treat Resident #288 with dignity and promote enhancement of her quality of life when the resident was not provided a privacy bag for his catheter bag. This failure could place residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 8 (Resident #13) residents reviewed for restraints. The facility failed to ensure they had physician orders for the scoop mattress being used for Resident #13. These failures could unnecessarily inhibit the residents' freedom of movement or activity.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (Resident #288 and Resident #7) of six residents reviewed for Care Plans. The facility failed to ensure Resident #288 was care planned for catheter care. The facility failed to ensure Resident #7 had interventions on her care plan for fall. These failures could place the residents at risk of needs not being met.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide an environment that was free from accident and hazards to prevent accidents for 1 (Resident #54) of 6 residents reviewed for accidents free of hazards. The facility failed to ensure Resident #54's fall mat was placed alongside her bed while she was laying in the bed. This failure placed the residents at risk of accidents and hazards. Findings Included: Record review of Resident #54's Face Sheet, dated 01/24/23, reflected she was an 82 -year-old female admitted on [DATE]. Relevant diagnoses included muscle wasting and atrophy (decrease in muscle tissue), and repeated falls. Record review of Resident #54's Quarterly MDS dated [DATE] reflected the resident's BIMS was 00 (Severe Cognitive Impairment). The MDS indicated the resident had an active diagnosis for syncope (fainting) and collapse. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #58 and Resident #10) of three residents reviewed for respiratory care. The facility failed to ensure Resident #58 and Resident #10's nasal cannula was properly stored when not in use. The facility failed to ensure Resident #58 and Resident #10's humidifier bottles had water in it. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure medical records were accurately documented for 1 of 3 residents (Resident #2) reviewed for notification of changes. The facility inaccurately documented that the family of Resident #2 was notified following a fall. This failure could place the residents at risk for not having accurate records.