Lake Woods Nursing & Rehabilitation Center

Inspectors wroteBased on observation interviews and record review, the facility failed to maintain the kitchen exhaust system, potentially decreasing the system's ability to capture grease, smoke and particulate matter.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and homelike environment for 4 bathrooms of 4 bathrooms observed for cleanliness.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records for 1 of 17 sampled residents (R61).

Inspectors wroteThis citation is related to intakes 2963901 and 2980259Based on interview and record review, the facility failed to complete a full assessment, after a fall and before moving one resident (Resident #100) out of three residents reviewed for accidents and hazards.

Inspectors wroteThis citation pertains to intake #2708299. Based on interview and record review, the facility failed to provide services according to professional standards of practice for 1 resident (R104) of 6 residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a pressure ulcer for 1 Resident (R26) of 2 Residents reviewed for pressure ulcers resulting in R26 developing a stage 3 pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteThis citation refers to MI00152461 Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse for 2 of 18 residents (R58, and R60), resulting in residents being physically abused.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician order for 1 of 17 sampled residents (R36), resulting in R36 not having a digoxin level checked for over a year.

Inspectors wroteR42 A review of R42's admission Record, dated 5/01/25, revealed they were an [AGE] year-old resident re-admitted to the facility on [DATE]. In addition, R42's admission Record revealed multiple diagnoses that included Vascular Dementia with behavioral disturbance, affective mood disorder, insomnia, and dysphagia oropharyngeal phase. A review of R42's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 03/31/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 99 which revealed R42 was severely cognitively impaired. Further review of R42's quarterly MDS reflected the resident only needed assistance with Setup or Clean-up for eating. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records for 2 of 17 sampled residents (R26 and R36).

Inspectors wroteBased on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living. Findings Include: During a tour of the facility with Maintenance Director I, starting at 1:29 PM on 4/29/25, observation of the spa room near activities, found a strong odor and bowel movement in the commode with clean folded towels stacked next to the sink. Further observation of the shower floor found an area near the front of the shower where roughly a dozen one-inch square tiles were missing. When asked if he was aware of the floor, MD I stated he was not. While looking for the missing tiles, MD I picked up a piece of trash on the shower floor and found it to be a gold tooth filling. When asked if he knew of any residents missing one, MD I was unsure. [...]

Inspectors wroteThis citation pertains to intake MI00146846. Based on interview and record review, the facility failed to 1.) Notify the Resident and Resident Representative in writing with the reason for a transfer out of the facility 2.) Send a discharge notice to a representative of the Office of the State Long Term Care (LTC) Ombudsman for a facility-initiated discharge, 3) Send discharge papers to the receiving hospital for 1 resident, Resident #1 (R1) of three residents reviewed for transfers and discharges, resulting in R1 receiving an involuntary discharge with no notice or place to live.

Inspectors wroteThis citation pertains to intake MI00146846. Based on interview and record review, the facility failed to allow a resident to return to the facility after being sent to the hospital for aggressive behavioral issues for one resident, Resident #1 (R1), of three residents reviewed for facility-initiated transfers, resulting in R1 being involuntary discharged to the hospital without a home to return to.

Inspectors wroteThis citation refers to MI00147470. Based on observation, interview, and record review, the facility failed to secure 1 of 3 medication carts (Harbor Medication Cart), resulting in the potential for misappropriation of resident medications.

Inspectors wroteThis citation refers to MI00147470. Based on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 1 of 83 facility residents (R9), resulting in the potential for unauthorized access to resident medical records and the potential for the loss of resident privacy and confidentiality of their personal health information.

Inspectors wroteThis citation pertains to intake #: MI00145370 Based on interviews and record review, the facility failed to protect a resident's (Resident #5) right to be free from physical abuse from another resident (Resident #4).

Inspectors wroteThis citation pertains to intake #: MI00146179 Based on observation, interview, and record review, the facility failed to ensure adequate supervision for 1 of 12 residents (Resident #1) reviewed for safety, resulting in R1 left unsupervised outside.

Inspectors wroteThis Citation pertains to Intake Number MI00144963. Based on observation, interview, and record the facility failed to protect the resident's right to be free from physical abuse by a resident for one resident (Resident #2) of three residents reviewed for abuse and neglect, resulting in Resident #2 being pushed, fracturing her right radius and the right femoral neck after falling.

Inspectors wroteBased on observations, interview and record review, the facility failed to assess, monitor, implement pressure relief and treat for wounds and pressures ulcers for 3 Residents (R23, R37, R48,) of 4 resident reviewed for pressure ulcers, resulting in R37 developing an unstageable pressure ulcer on his back and a new pressure ulcer on his right thigh, R48's wound on her leg increasing in size and the pressure ulcer on her buttock worsening, and R23 missing wound treatments/assessments.

Inspectors wroteThis citation pertains to intake #MI00143643 and MI00144325. Based on observations, interviews and record review the facility failed to follow standards of care for 5 Residents (R20, R39, R78, R135, R136) out of 28 sampled residents, resulting in R39 not having her lower extremities assessed and evaluated by her physician, R78 not having his wounds treated as ordered, R20 potentially having a serious medication error and R135 and R136 not having a complete set of neurological assessments after a fall. R39 Review of R39's face sheet dated 5/20/24 revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included chronic kidney disease, stage 3, muscle weakness, weakness and need for assistance with personal care. R39 was her own responsible party. R39 was observed in bed on 5/13/24 at 1:28 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident choices were honored for one of four residents (Resident #26) reviewed for choices, resulting in feelings of frustration and distress.

Inspectors wroteThis citation pertains to intake MI00144325. Based on interview and record review, the facility failed to notify the responsible party after resident falls for 2 residents (Resident #135 and #58) of 2 residents reviewed for notification of changes, resulting in the physician and family/guardian not being notified of resident changes of condition and the potential for delayed medical intervention and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement policies and procedures for ensuring the reporting of a resident-to-resident incident for 2 residents' (R7 & R26) out of 13 residents reviewed for abuse and neglect, resulting in the potential for ongoing abuse and/or neglect.

Inspectors wroteThe following citation pertains to intake #MI00143643. Based on interview and record review, the facility failed to revise care plans for 2 residents (Resident #136 and #23) of 3 residents reviewed for care plan revision, resulting in Resident #136's care plan not being revised after a fall and Resident 23's care plan not being revised with the development and worsening of pressure ulcers.

Inspectors wroteBased on observation, interview and record review the facility failed to provide 1 Resident (R78) with scheduled showers of 3 Residents reviewed for activities of daily living, resulting in R78 having feelings of frustration.

Inspectors wroteThis citation refers to MI00144528. Based on interview and record review, the facility failed to: 1) prevent an elopement for 1 of 1 resident (R73) reviewed for elopements and 2) failed to complete post-fall assessments on 1 of 3 residents (R58) reviewed for falls, resulting in R73 leaving the facility unbeknownst to staff, the potential for R73 sustaining serious injuries during the elopement, and the potential for staff not identifying a change in condition timely for R58 which could result in a serious physical outcome post-fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders to clean and flush a catheter for 1 (R37) of 4 residents reviewed for catheter care and management.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide palatable food for 1 Resident (R48) of 28 sampled residents, resulting in the potential for poor nutrition and poor wound healing.

Inspectors wroteBased on observation, interview, and record reveiew, the facility failed ensure 1 resident (R64) of 1 Resident reviewed for therapy services, had follow up appointment related to medical equipment needed for physical therapy, resulting in pain and frustration with the use of the equipment.

Inspectors wroteThis citation refers to MI00142853 and the annual survey Based on interview and record review, the facility failed to maintain complete and accurate medical records for 3 of 29 (R5, R26, and R137) sampled residents, resulting in the potential for providers not having an accurate and complete picture of the resident's stay at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clean and sanitary medical equipment at bedside for one Resident (R53) reviewed, resulting in the potential for the use of an unsanitary medical device.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards and infectious disease outbreaks.

Inspectors wroteThis citation pertains to intake MI00142132 Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls for 1 Resident (R6) of 3 residents reviewed for falls, resulting in R6 having multiple avoidable falls.

Inspectors wroteThis citation pertains to intake MI00142132 and MI00142485 Based on observations, interviews and record review, the facility failed to provide adequate pain relief, accurate assessment of pain, and pain medication as ordered to 2 Residents (R5 and R7), resulting in R5 and R7 experiencing unnecessary pain.

Inspectors wroteThis citation pertains to intake MI00142132 Based on interview and record review the facility failed to accurately account for the dispensing of 4 Residents (R5, R7, R8, R9) narcotic medications of 4 Residents reviewed for narcotic medication use, resulting in the potential for overdose, missing doses, and drug diversion.

Inspectors wroteThis citation pertains to intake MI00142132 Based on observation, interview, and record review, the facility failed to ensure 1 of 3 medication carts were under double lock for controlled substances and accounted for each shift change by 2 nurses.

Inspectors wroteThis citation pertains to intake MI00142132 and MI00142485 Based on observations, interview and record review, the facility failed to treat 2 Residents (R5 and R7) of two reviewed with dignity, resulting in pain and feelings of frustration.

Inspectors wroteThis citation refers to MI00139088. Based on observation, interview, and record review, the facility failed to prevent an elopement resulting in an immediate jeopardy when one Resident (R14) who was a known elopement risk, of three residents reviewed for elopement risk, was let outdoors by a staff member who did not know the resident. This deficient practice resulted in the elopement and potential for serious harm, injury, impairment, or death to R14 and all other residents assessed as an elopement risk.

Inspectors wroteThis intake pertains to intake number MI00136899, MI00138532 and MI00138627. Based on observations, interviews, and record review the facility failed to assess, monitor and treat 2 Residents' (R2 and R12) medical needs, resulting in R2 not being adequately assessed for fluid retention and requiring hospitalization/treatment for fluid retention and R12 not being provided post-surgical care as directed by her surgeon.

Inspectors wroteThis intake pertains to intake MI00138532, MI00138627 and MI00138674 Based on observations, interviews, and record reviews, the facility failed to provide adequate nursing staffing to meet 1 Resident's (R12) care needs resulting in R12 not receiving timely incontinence care and other care in a timely manner.