Lane House, the

Inspectors wroteBased on interview and record review, the facility failed to ensure a cognitively intact resident with new onset altered mental status and vomiting was monitored and treated timely resulting in the resident having a delay in treatment and death for 1 of 3 residents reviewed for quality of care (Resident B). The immediate jeopardy began on [DATE] at 10:46 a.m. when a cognitively intact resident had new onset symptoms of coughing, coffee ground emesis, complaints of feeling drunk, and staggering while ambulating. The physician ordered a Complete Blood Count (CBC) that was not obtained. The record lacked documentation of the resident's condition on [DATE]. On [DATE] the resident had altered mental status, dizziness, abdominal pain, and his pulse was 128. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately notify the resident's family, and/or emergency contact when a cognitively intact resident developed new onset altered mental status, vomiting, and physical decline for 1 of 3 residents reviewed for family notification (Residents B).

Inspectors wroteBased on interview and record review, the facility failed to ensure staff ordered, obtained, and tracked STAT (immediately) laboratory orders for 1 of 3 residents reviewed for completion of laboratory orders (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to accurately complete an elopement risk assessment for a vulnerable resident who was found outside the facility, on the grass after falling out of his wheelchair, without the knowledge of staff for 1 of 3 residents reviewed for neglect (Resident C). The deficient practice was corrected by 9/8/25 prior to the start of the survey and was therefore past noncompliance.

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to ensure the low temperature dish machine (a commercial dishwashing machine that relies on chemical sanitizers, rather than high temperatures, to sanitize dishes, typically operating at temperatures between 120° Fahrenheit [F] and 140 F) wash and rinse temperatures met minimum standards and the March 2025 logs for the dish machine temperatures were completed for 1 of 2 kitchen observations. This had the potential to affect all residents who consumed food or liquids from the kitchen. B. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure a sanitary environment was maintained for residents during meal service for 2 of 2 random observations. This had the potential to affect all residents on the [NAME] Hall consuming food during the use of cleaning supplies.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure falls were documented, interventions implemented, and a call light was within the resident's reach for 1 of 2 residents reviewed for falls (Resident 29).

Inspectors wroteBased on record review and interview, the facility failed to address a significant weight discrepancy for 2 of 4 residents reviewed for nutrition and the facility failed to obtain daily weights for 1 of 4 residents reviewed for weights (Residents 27, 17, and 21).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure proper storage of respiratory equipment for 1 of 2 residents reviewed for respiratory care (Resident 14).

Inspectors wroteBased on record review and interview, the facility failed to ensure behaviors were documented to support the declination of a medication gradual dose reduction (GDR) for 1 of 5 residents reviewed for unnecessary medications (Resident 36).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure keys to the medication room were kept in an area only accessible to nursing staff, food was not kept in the medication room, multi-use medication containers were dated when opened, and insulin was disposed of once it was past the use by date for 1 of 1 medication rooms reviewed and 1 of 2 medication carts reviewed (Residents 33 and 12).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate staffing sheets were posted daily for 3 of 5 days during the recertification survey.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a dependent resident had adequate supervision, a safe environment, and was provided care to remain free from injuries of unknown origin for 1 of 3 residents reviewed for accidents (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's gastrostomy tube (g-tube-a tube inserted through the belly that brings nutrition directly to the stomach) was maintained in a clean and sanitary condition, for 1 of 2 residents reviewed for g-tube (Resident C). The deficient practice was corrected on 7/17/24, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hair restraints (hair covering and nets, beard restraints, and clothing that cover body hair) were worn in the kitchen during meal service and preparation during 2 of 2 kitchen observations.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident was transferred properly for 1 of 1 resident reviewed for accidents (Resident 14).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure they were free of a medication error of 5% or higher with an error rate of 6.67% for 1 of 5 residents observed for medication administration (Resident 24).

Inspectors wroteBased on record review, the facility failed to ensure the medical record of medication administration was accurately documented for 1 of 5 residents reviewed (Resident 31). Findings Include: On 2/15/24 at 10:52 a.m., the medical record of Resident 31was reviewed. The resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper handling of medication patches during the medication administration pass for 2 of 5 residents reviewed during medication administration (Residents 9 and 26).

Inspectors wroteBased on observation and interview the facility failed to maintain all mechanical equipment was kept in safe operating condition for 2 of 2 observations of the laundry service area. Findings Include: On 2/19/24 at 11:02 a.m., during routine observation of the laundry service area, two large fans were observed. The fan blades and the fan cage covering the blades were coated in a thick layer of grey lint. On the floor behind washers were a large amount of grey lint and debris. Lint traps in two dryers contained a moderate amount of lint on the screens. The cleaning logs indicated the lint traps were cleaned frequently. The lint on the fans and behind the washers created a risk for fire hazard. On 2/19/24 at 1:30 p.m., during an interview with the Administrator indicated the fans and floors of the laundry area must be kept clean and free of lint. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's rights had been reviewed with the members of the Resident Council, during the monthly scheduled meetings, for 3 of 3 residents who attended the Resident Council interview.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident had the right to be free from physical abuse and coercion when she was forcibly given a shower against her will for 1 of 1 resident reviewed for abuse (Resident 19).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure orders for a hand splint were re-initiated upon return from the hospital and implemented to prevent the potential for worsening contractures and skin break down for 1 of 1 resident reviewed for Range of Motion (ROM) services (Resident 14).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to identify a resident, (Resident D) at a higher risk for the development of serious urinary tract infections (UTIs) due to her history of UTIs and the presentation of her intellectual/developmental disabilities which at baseline, often closely resembled common symptoms of a UTI, which resulted in 2 of 3 hospitalizations for sepsis, secondary to UTIs. This deficient practice had the potential to effect 1 of 2 residents reviewed for UTIs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask was stored properly for 1 of 1 residents reviewed for respiratory (Resident 28).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the general cleanliness of food storage areas was maintained and failed to ensure the air conditioning (AC) grated vents were cleaned to prevent potential for contamination of uncovered foods for 1 of 2 kitchen observations. These deficient practices had the potential to effect 42 of 42 residents served from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted daily for 1 of 7 observations of staff postings.