Lakepoint El Dorado, LLC

Inspectors wrote- The Electronic Medical Record (EMR) for R11 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type 2, dementia (a progressive mental disorder characterized by failing memory and confusion), chronic respiratory failure (occurs when the lungs are unable to exchange oxygen and carbon dioxide in the blood properly) with hypoxia (inadequate supply of oxygen), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). [...]

Inspectors wrote- The Electronic Medical Record (EMR) for R11 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type 2, dementia (a progressive mental disorder characterized by failing memory and confusion), chronic respiratory failure (occurs when the lungs are unable to exchange oxygen and carbon dioxide in the blood properly) with hypoxia (inadequate supply of oxygen), hypertension (high blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). [...]

Inspectors wroteThe facility had a census of 55 residents. The sample included 15 residents with five reviewed for drug regimen. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R)1 and R18's blood pressure medication was administered outside the physician-ordered parameters and R20 and R31s' use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) with an unapproved diagnosis. This placed the residents at risk for inappropriate use of medication and related complications.

Inspectors wroteThe facility had a census of 55 residents. The sample included 15 residents and 25 medication administrations observed. Based on observation, record review, and interview, the facility failed to ensure a medication error rate less than 5 percent (%). This placed the residents in the facility who received medications at risk for physical decline and other related complications.

Inspectors wroteThe facility had a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure the medications and biologicals were stored and monitored appropriately in one of two medication rooms. This placed the affected residents at risk of ineffective medication.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents reviewed for care plans. Based on observation, record review, and interview, the facility failed to ensure staff developed and implemented a comprehensive care plan for Resident (R) 29 that included care and interventions for dialysis (a procedure where impurities or wastes are removed from the blood). The facility failed to develop and implement a comprehensive care plan for R36 to address diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and insulin use. This placed R29 and R36 at risk of impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 55 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to follow up with the physician for direction when one resident, Resident (R) 10 became ill with a productive cough and coarse lung sounds. This placed R10 at risk for physical decline and complications due to delayed physician involvement.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents with two residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 42's low air loss mattress (a mattress designed to prevent and treat pressure wounds) was functioning which resulted in an avoidable fall. The facility failed to ensure R50 was assessed for the safe use of a recliner or the need for updated toileting interventions after sustaining falls to prevent further falls. This placed R42 and R50 at risk for preventable falls and possible injuries.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents with Resident (R) 29 reviewed for dialysis (a procedure where impurities or wastes are removed from the blood), nutrition, and hydration. Based on observation, record review, and interview, the facility failed to ensure R29's physician-ordered fluid restriction was followed, monitored, and documented. This placed R29 at risk of fluid overload and related complications.

Inspectors wroteThe facility identified a census of 55 residents. The sample included 15 residents with one resident reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 2's post-traumatic stress disorder (PTSD - mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R2 at risk for decreased psychosocial well-being and ineffective treatment.

Inspectors wroteThe facility had a census of 55 residents. The sample included 15 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medications per the physician-ordered parameters for two residents, Resident (R) 18 and R1. This placed the resident at risk for physical decline and other related complications.

Inspectors wrote- R31's Electronic Medical Record (EMR) documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) with behavioral disturbances, major depressive disorder (major mood disorder that causes persistent feelings of sadness), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), and hypertension (HTN - elevated blood pressure) R31's Significant Change Minimum Data Set (MDS) dated [DATE] documented she had both short and long-term memory problems. R31 had severely impaired cognitive skills for daily decision-making. R31 had continuous behaviors of inattention and disorganized thinking. R31 had delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue). R31 had impairment on both sides of her lower extremities. [...]

Inspectors wrote- R42's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), and repeated falls. R42's Significant Change Minimum Data Set (MDS) dated [DATE] documented short- and long-term memory problems. R42 had severely impaired decision-making skills and showed signs and symptoms of delirium (sudden severe confusion, disorientation, and restlessness). [...]

Inspectors wroteThe facility reported a census of 52 residents, with three residents sampled for abuse. Based on observation, record review, and interview, the facility failed to prevent the sexual abuse of cognitively impaired Resident (R) 3, who lacked the ability to consent. On 07/09/24 at approximately 03:30 PM to 04:00 PM, Certified Nurse Aide (CNA) N observed cognitively intact R2, who had a history of touching R3, with his hand inside R3's pant leg to her groin area. R3 had severe cognitive impairment and inability to consent, placing her in immediate jeopardy, based on a reasonable person concept, and at risk for trauma and a negative psychosocial impact.

Inspectors wroteThe facility reported a census of 52 residents, with three residents sampled for abuse. Based on observation, record review, and interview, the facility failed to protect cognitively impaired Resident (R) 3, who lacked the ability to consent, from sexual abuse. On 07/09/24 at approximately 03:30 PM to 04:00 PM, Certified Nurse Aide (CNA) N observed cognitively intact R2, who had a history of touching R3, with his hand inside R3's pant leg to her groin area. R3 had severe cognitive impairment and inability to consent, placing her in immediate jeopardy, based on a reasonable person concept, and at risk for trauma and a negative psychosocial impact.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents, with six reviewed for side rails. Based on observation, record review, and interview, the facility failed to assess Resident (R)14, R 17, R1, R12, R21 and R20s' side rails for safe use. This deficient practice placed the six residents at risk for entrapment or injury.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents of which five were reviewed for immunization status. Based on record review and interview, the facility failed to offer and provide the residents and/or their representative the current years Influenza Vaccine Information Statement (VIS-informed sheets produced by the CDC [Centers for Disease Control and Prevention] that explained both the benefits and risk of vaccine to vaccine recipients for Resident (R)4, R12, R17, R20 and R25. This placed the affected residents at increased risk for illness and infection.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents. Based on observation, record review and interview, the failed to review and revise Resident (R) 10's plan of care with resident-centered interventions to prevent falls, which placed the R10 at risk of further falls and injury.

Inspectors wroteThe facility had a census of 32 and the sample included 14 residents, with seven reviewed for accidents. Based on observation, record review and interview the facility failed to identify and implement interventions to prevent falls for Resident (R)10 and failed to apply antiroll back devices to R20's wheelchair to prevent further falls, which placed the residents at risk for ongoing falls and injuries.

Inspectors wroteThe facility had a census of 32 residents. The sample included 14 residents, with six reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure the Consultant Pharmacist identified and reported to the Director of Nursing, facility medical director, and physician, the lack of a 14 day stop date for Resident (R)26's as needed (PRN) psychotropic (a medication that affects mood and/or thought) or rationale for use. This placed the resident at risk for inappropriate use of a psychotropic medication with side effects.

Inspectors wroteThe facility had a census of 32 residents. The sample included 17 residents, with six reviewed for unnecessary medications. Based on observations, interview and record review, the facility failed to ensure a 14- day stop date for Resident (R) 26 and R10 who received as needed (PRN) psychotropic (medication that affects mood and/or thoughts) medication that lacked a rationale for continued use. This placed the affected residents at risk for unintended affects related to psychotropic drug medications.

Inspectors wroteThe facility reported a census of 51 residents with 16 selected for review, which included four residents reviewed for pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure appropriate pressure relieving interventions were in place for one resident (R)13, who had a worsening pressure ulcer on her lateral (side) shin area. In addition, the facility failed to provide sanitary pressure ulcer dressing changes for three residents, R13, R49 and R3, also reviewed for pressure ulcers. Findings Included: [...]

Inspectors wroteThe facility reported a census of 51 residents with 16 selected for review. Based on interview and record review, the facility failed to ensure the development of a base line care plan for one selected resident (R)55, within 48 hours of admission and to include the minimum healthcare information necessary to properly care for a resident.

Inspectors wroteThe facility reported a census of 51 residents with 16 selected for review. Based on observation, interview and record review, the facility failed to review and revise the care plan for one resident (R)13, who developed stage three pressure ulcer to her coccyx and stage four pressure ulcer to her left shin, after determining the heel lift device caused the pressure injury to her shins. Findings Included: [...]

Inspectors wrote- The signed Physician Order Sheet (POS), dated 07/01/21, documented R21 had the following diagnoses: cerebral infarction (also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area), subdural hematoma (collection of blood on the surface of the brain), and dementia (progressive mental disorder characterized by failing memory, confusion) in other diseases. A significant change Minimum Data Set (MDS), dated [DATE], documented R21's Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment. She required extensive assistance with bed mobility, transfer, dressing, toileting, and personal hygiene. A Falls Care Area Assessment, dated 09/18/20, documented R21 had a change due to decline in cognitive functioning, communication, and a decline in her ability to perform activities of daily living. [...]