Lakeland Hills Center

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to accurately document procedures for a Cardiopulmonary Resuscitation (CPR) event for one (#2) of three resident reviewed for CPR.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure medications were stored in accordance of current professional standards for two (Residents #128 and #57) of 25 sampled residents and in four of four medication carts.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide a private space for the resident council to meet and failed to respond to the council's concerns and/or suggestions during five of six Resident Council Meeting Minutes.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure water temperatures were comfortable for one (400 hall) of four hallways sampled.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to obtain Preadmission Screening and Resident Review (PASARR) Level II evaluations for (#8 and #9) of thirty-five initially sampled residents prior to facility admission.

Inspectors wroteBased on observation, record review and interview the facility failed to create a resident centered care plan for two (Resident #8 and #36) related to medications out of five residents sampled.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents received activities of daily living (ADL) care timely, for one (Resident #139) out of two residents reviewed for ADL care. Findings Included: During an interview on 03/09/2026 at 09:39 AM, Resident #139 stated having used a call light earlier in the day. Resident #139 stated staff answered the call light, and she told them she had urinated and had a bowel movement. Resident #139 stated she was changed two hours later. Resident #139 explained having again urinated and was waiting to be changed by staff at the time of the interview. The resident explained being upset about having to wait two hours to be changed by staff. During an interview on 03/11/2026 at 12:57 PM, Resident #139 stated at 11:00 AM, the Social Services Director (SSD), asked if assistance was needed. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide life enriching activities for one (#2) of one dependent resident sampled for activities.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure two (Resident #2 and #122) of two residents reviewed were managed with professional standards and facility policy.

Inspectors wroteBased on record review and interview the facility failed to provide social services to one (Resident #11) out of 25 residents sampled. Findings Included:During an interview on 03/09/2026 at 10:52 a.m., Resident #11 stated he has not received a social security check in over a year. I have talked to several people and they tell me they are working on it and never follow up with me. I have no money to buy anything that I need. Review of Resident #11's minimum data set (MDS) dated [DATE] revealed Section C. Cognition, a brief interview mental status of 15 out of 15 showing intact cognition. Review of Resident #11's progress notes revealed:Social services progress note dated 6/5/2025, social services director (SSD) called the business office manager and inquired about the previous facility. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to initiate consulting pharmacist recommendations within the expected 30-day time frame for two (#8 and #57) of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide laboratory services for one (#8) of five residents sampled for unnecessary medications.

Inspectors wroteBased on observation, record review, interviews, and the Plan of Correction review, the facility did not ensure it had a functioning Quality Assurance Committee. The facility was actively involved in the creation, implementation, and monitoring of the plan of correction for deficient practice identified during a recertification survey ending on 3/12/2026 and was cited F656, F761, F925. The facility had developed a Plan of Correction with a completion date 4/12/2026. The facility had not comprehensively implemented the plan of correction related to 1) implementing resident centered care plans related to prevention of self-harm for one (Resident #3) of three residents; 2) ensuring medications were stored in accordance with current professional standards for four of four medication carts and medications stored at bedside for for one (Resident #3) of twenty-four; [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure its pest control program was effective on four of four hallways.

Inspectors wroteBased on record review and interviews, the facility failed to protect the residents' right to be free from neglect for four residents (#4, #5, #3, and #2) out of six residents sampled related to 1) failure to accurately reconcile medications, 2) failure to follow-up on physician orders for laboratory testing, medical equipment, and outpatient services, 3) failure to provide medication with a physician's order, 4) failure to follow a physician's order for blood sugar testing, and 5) failure to implement hospice consultation orders. Serious harm occurred on [DATE], when Resident #4's seizure medications were not reconciled accurately, resulting in Resident #4 experiencing two seizures. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for six residents (#4, #5, #1, #3, #6, and #2) out of ten residents sampled related to 1) failure to accurately reconcile medications upon admission, 2) failure to follow-up on laboratory orders, 3) failure to provide medication only with a physician's order, 4) failure to report and document malfunctions with a gastrostomy tube (G-tube), 5) failure to practice within the nursing scope of responsibility, 5) failure to follow a physician's order related to blood sugar testing, and 6) failure to implement hospice consultation orders. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to residents and resulted in the determination of Immediate Jeopardy on 04/07/2025. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure three residents (#4, #5, and #3) out of six residents sampled for medication administration were free from a significant medication error as evidenced by 1) failure to accurately reconcile medications upon admission, and 2) failure to provide physician ordered medications. Serious harm occurred on [DATE], when Resident #4's seizure medications were not reconciled accurately, resulting in Resident #4 experiencing two seizures. After the seizures, physician ordered laboratory tests for seizure medication levels were not implemented, and Resident #4 had a third seizure resulting in a fall with head trauma and transfer to a higher level of care. Resident #4 subsequently died from his injuries. [...]

Inspectors wroteBased on interviews and record review, the facility Quality Assurance and Performance Improvement Committee (QAPI) failed to implement an effective Performance Improvement Plan (PIP) related to Diabetes Management for one out of two sampled QAPI plans reviewed.

Inspectors wroteBased on observations and interviews, the facility failed to ensure essential laundry equipment was in safe operating condition for one of two industrial dryers, which limited the availability of clean linen for resident care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a safe, clean, and comfortable environment for two residents (#7 and #8) of eight sampled residents.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the implementation of the care plan for one resident (#6) of eight sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food was stored, prepared, and handled safely in accordance with professional standards for food service safety. The facility failed to ensure food and beverages were labeled, dietary staff members donned gloves as necessary, cleanliness of a drying rack, cookware was sanitized and clean, plates were not chipped, and the thermometer was calibrated appropriately in one of one kitchen.

Inspectors wroteBased on observations, interviews, and record review the facility failed to implement an effective infection control program as evidence by 1) failure to handle, store, process, and transport all linens and laundry in accordance with appropriate infection control practices to produce hygienically clean laundry for 104 out of 104 residents, and 2) failure to ensure appropriate hand hygiene was completed after delivering a meal tray to one isolation room (room [ROOM NUMBER]) of one isolation rooms, and 5 rooms (room [ROOM NUMBER], 308, 310, 311 and 313)out of 15 rooms observed for meal service.

Inspectors wroteBased on interviews and record review, the facility failed to act upon grievances expressed in Resident Council Meetings.

Inspectors wroteBased on observations, interviews, and record review, the facility failed implement an effective performance improvement plan for resident concerns voiced at resident council meetings related to diet accuracy and timeliness of meal service.

Inspectors wroteBased on interviews and record review, the facility failed to assure the accuracy of the Pre-admission Screening and Resident Review (PASRR) for two residents (#14 and #45) related to the diagnosis of a Serious Mental Illness (SMI) and/or an Intellectual Disability out of six sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon having a qualifying mental health diagnosis for two residents (#26 and #64) out of six residents sampled for PASARR Level II screenings.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide a physician-ordered and resident preferred diet to one resident (#45) out of three residents sampled for nutrition.

Inspectors wroteBased on interview and record review the facility failed to accurately follow up on pharmacy recommendations for two residents (#81 and #9) of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less that 5.00%. Thirty-two medication administration opportunities were observed and three errors were identified for two residents (#51 and #83) of five residents observed. These errors constituted a 9.38% medication error rate.

Inspectors wroteBased on observations, interviews, and record review, the facility 1) failed to ensure a change in condition for one resident (#14) out of forty-two sampled residents was acted upon per physician orders in a timely manner and, 2) failed to provide medications for one resident (#16) out of six residents with percutaneous endoscopic gastrostomies (PEG tubes) per physician orders and professional standards of practice.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure that medications were delivered in the manner prescribed for one resident (#21) of seven sampled residents. This resulted in medications being administered as crushed without an order or approval from the prescribing physician. The five errors observed during medication administration observations of 25 medications, represented an error rate of 20%.