Lotus Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to: Ensure the lid on an opened container of jelly was closed. Ensure a package of sandwich meat was stored in a closed container after being opened. Ensure staff were monitoring temperatures in 2/2 dry food storage rooms by placing thermometers inside. These deficient practices had the potential to result in contamination of food served to the residents.

Inspectors wroteBased on interview and record review the facility failed to:1. Ensure one of five sampled residents (Resident 30) Practitioner Orders for Life-Sustaining Treatment ([POLST] - a medical order form that documents specific medical treatment in the event of a medical emergency) part D of the form was completed. This deficient practice of not having the POLST completed had the potential for Resident 30's wishes not to be carried out in the time of distress. During a review of Resident 30's admission Record (Face Sheet), the Face Sheet indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Report to the physician a change in condition when sediments (the solid matter that settles to the bottom of a liquid, such as urine) and cloudy urine were observed in the indwelling urine catheter (a medical device inserted into the bladder to drain urine continuously) tubing for one of one sampled resident (Resident 2). This deficient practice had the potential to delay clinical assessment and timely medical intervention.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure the Minimum Data Set (MDS) resident assessment accurately reflected tobacco use status for two of 13 sampled residents (Residents 8 and 17). The MDS coded the residents as non-tobacco users despite documentation and staff confirming tobacco use within the required look-back period. This deficient practice had the potential to affect the accuracy of resident assessment data used for care planning, quality measures, and facility monitoring of smoking-related safety needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Maintain equipment in the kitchen when it was observed that the freezer was not kept at a temperature less than or equal to 0 degrees Fahrenheit. This deficient practice had the potential to result in contamination of food served to the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure each resident had at least 80 square feet ([sq. ft.]- is a unit of, area measurement) of measured living space in rooms 1, 6, 7, 8, 9, 11,12,15,16, and 17. This deficient practice had the potential to result in residents not being able to move around freely, store personal items, and for staff to have difficulty providing care for the residents due to the lack of space. During an observation on 2/13/2026 at 2:15 p.m., room [ROOM NUMBER] had three occupied residents' beds with a total of four beds in the room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were stored in a manner to prevent the growth of microorganisms that could cause food borne illnesses (any illness resulting from spoiled or contaminated food). This deficient practice had the potential to cause food borne illnesses for residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the laundry room was free from personal food items. This deficient practice had the potential to spread infection throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS]- a federally mandated assessment tool), for one of eight sampled residents (Resident 1). This deficient practice had the potential to result in inaccurate care and services for Resident 1 due to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 15) had a care plan developed to address smoking. This deficient practice had the potential to result in a lack of monitoring and risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a change of condition and notify the doctor of bruising for one out of one sampled resident (Resident 24) who was receiving Eliquis (a blood thinning medication). This deficient practice had the potential to delay necessary care and services for Resident 24.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled employees had an annual skills checklist completed. This deficient practice had the potential to result in substandard quality of care to residents due to a lack of training/assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled residents (Resident 27) received a monthly Medication Regimen Review ([MRR] evaluation of medications to identify issues) by the pharmacist. This deficient practice put Resident 27 at risk for an adverse drug reaction (harmful response).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three bottles of Enulose (medication used to help with a brain disorder caused by liver disease) in medication Cart 1 was free of sticky residue. This deficient practice put residents at risk for infection related to cross contamination (transfer of bacteria from one object another).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all dumpsters were kept closed. This deficient practice had the potential to attract flies and rodents to the dumpster area.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of eight sampled residents (Resident 24). This deficient practice had the potential to negatively impact the continuity of care and delivery of services for Resident 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had at least 80 square feet (sqft, unit of measure of living space in Rooms 1, 6, 7, 8, 9, 11, 12, 14, 15, 16, and 17. This deficient practice had the potential to result in residents not being able to move around freely or store personal items, and staff may also have difficulty providing care due to a lack of space.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility ' s telephone system was able to receive outside calls from one of three resident ' s (Resident 1) representative or an outside caller. This deficient practice had the potential for all the residents in the facility not receiving phone calls from family members.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the low air loss mattress ([LAL] special mattress for wound management) for one of three sampled residents (Resident 1), as ordered by the physician. This failure placed the resident ' s wound at risk for poor healing and worsening condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, two of seven sampled residents (Resident 3 and Resident 32), were assisted with nail hygiene and Resident 32 did not have a dry and scaly feet. This deficient practice had the potential for Resident 3 and Resident 32 to scratch themselves, result in itchy skin and can result in skin breakdown.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to to ensure hygiene products that were stored in the facility's central supply room were not expired. This deficient practice had the potential for the products to lose its effectiveness and strength and can result to a skin reaction or any adverse reactions to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for two out of 17 sampled residents (Resident 28 and 22) Level 2 (a person-centered evaluation completed for anyone identified by the Level I Screening as having, or suspected of having, a PASRR condition, i.e serious mental illness, intellectual disability, developmental disability or related condition to determine whether placement or continued stay in a Nursing Facility is appropriate), were completed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food products stored in the freezer were labeled use by dates (last date recommended for the use of the product while at peak quality) as per the facility's policy and procedure. This deficient practice can affect the palatability (taste) of the food prepared and had the potential to place the residents at risk for food borne illnesses. Findings During an observation on 10/21/2023 at 7:44 a.m. in the kitchen, three bags of hash browns and three bags of tater tots (shaped diced potatoes for cooking) were in the freezer and had no label when the bags were received and had no use by (last date recommended for the use of the product while at peak quality) dates. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required 80 square feet per resident in a multiple resident bedrooms (Rooms 1, 6, 7, 8, 9, 11, 12, 14, 15, 16 and 17) and 100 square feet per resident in single resident rooms (Rooms 2, 3, 4, 5, 10). This deficient practice had the reduced required space for each resident which had the potential for inadequate space during resident care, and or the inability for resident access, use of personal assistive devices, furniture, and enough space for the visitors.