Mayo Clinic Health System - Lake City

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess a significant weight increase and implement care-planned monitoring for edema and signs and symptoms of congestive heart failure for 1 of 3 residents (R4) reviewed for change in condition.

Inspectors wroteBased on interview and document review the facility failed to ensure laboratory reports were filed in the clinical record for 1 of 1 resident (R4) reviewed for edema monitoring.

Inspectors wroteBased on interviews and document review the facility failed to maintain a complete, accurate and readily accessible medical record was maintained for 2 of 3 residents (R1, R3) who were noted to have missing information in their record.

Inspectors wroteBased on observation, interview and document review, the facility failed to protect 1 of 1 resident (R1) who had severe cognitive impairment and was unable to give consent for sexual activity from inappropriate sexual touching from R2, who had known history of sexually inappropriate behavior resulting in R2 placing his hand underneath R1's shirt and touching her breast on 4/4/26. This deficient practice resulted in immediate jeopardy (IJ) for R1, as a reasonable person would have experienced severe psychosocial harm, including dehumanization and humiliation as a result of sexual abuse. The Immediate Jeopardy (IJ) began on 4/4/26, when R1's breast was touched by R2 after the facility failed to develop and implement individualized interventions including clearly defined supervision to prevent R2's access to female residents despite a known history of sexually inappropriate behavior. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident-to-resident sexual abuse involving 2 of 2 residents (R1) and (R2) to law enforcement, in accordance with established policies and procedures for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation of an allegation of resident-to-resident sexual abuse for 2 of 2 residents (R1) and (R2), including failure to complete staff and resident interviews and failure to fully assess the circumstances surrounding the incident, reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for 1 of 1 resident (R2) when staff did not consistently document episodes of sexually inappropriate comments toward staff, resulting in gaps in behavioral tracking and an inability to accurately evaluate the frequency and severity of R2's behaviors, reviewed for abuse.

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess sling/harness sizes according to manufacturer's instructions to ensure safe transfers for 2 of 2 residents (R1 and R3) who utilized mechanical lifts sit to stand lift and full body mechanical lifts for transfers.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure enhanced barrier precautions (EBP) were implemented with the use of personal protective equipment (PPE) during high-contact resident care activities for 1 of 1 residents (R5) who had a foley catheter, and failed to ensure shared resident equipment was disinfected between uses.

Inspectors wroteBased on interviews and document reviews, the facility did not assess or analyze trends in falls to determine causal factors or root causes and implemented individualized interventions aimed at preventing or reducing the risk of falls with major injuries for one of three residents (R1) who experienced falls. This resulted in actual harm when R1 suffered two thoracic spinal fractures and hospitalization after he was left unsupervised on the commode and fell.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered to the correct resident for 1 of 3 residents (R1) reviewed for medication errors. This failure resulted in actual harm when R1 became hypotensive that required treatment in the emergency department (ED) and ongoing symptom monitoring and treatment. The facility had implemented appropriate corrective action prior to the onsite investigation so the deficiency is being cited at past non-compliance.

Inspectors wroteBased on interview and document review, the facility failed to provide the required written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms to 3 of 3 residents (R2, R162, R258) reviewed whose Medicare A coverage ended and then remained in the facility and/or discharged home.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for 1 of 1 resident's reviewed for wandering.

Inspectors wroteBased on interview and document review, the facility failed to ensure medications were administered per physician's order for 1 of 1 resident (R40) reviewed for assessment prior to medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with repositioning to promote healing of pressure ulcer for 1 of 1 resident (R4) in accordance with the individualized care plan.

Inspectors wroteBased on observation, interview and document review, the facility failed to investigate, review and analyze underlying causes of resident's anxiety and agitation for 1 of 1 resident (R24) who was reviewed for behaviors.

Inspectors wroteBased on interview and record review the facility failed to follow up on provider orders for 1 of 1 (R26) residents reviewed for dementia care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure proper hand hygiene was completed when assisting with therapy for 1 of 2 residents (R38) whose therapy care was observed. In addition, the facility failed to ensure soiled and potentially contaminated laundry was sorted in a manner to reduce the risk of cross contamination and subsequent infection spread. These findings had the potential to affect all 58 residents who utilized laundry services.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 residents (R40) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s).

Inspectors wroteBased on interview and observation the facility failed to ensure residents received mail timely on weekends. This has the potential to affect all residents in the facility who receive mail.

Inspectors wroteBased on interview and document review the facility failed to obtain informed consent for a psychotropic medication (medication that affects behavior, mood thought or perception) for 1 of 1 residents (R1) reviewed for neglect in relation to medications.

Inspectors wroteBased on interview and record review the facility failed to ensure allegations of staff to resident abuse were immediately reported to the State Agency (SA) no later than 2 hours after the knowledge of the allegation of abuse, for 1 of 1 residents (R1) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to notify the Long-Term Care (LTC) ombudsman of a facility-initiated transfer for 1 of 1 residents (R1) who was transferred to an acute care facility on an emergency basis reviewed for hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to ensure a written notice of bed hold was provided in a timely manner for 1 of 1 resident (R1), reviewed for hospitalization.

Inspectors wroteBased on interview and document review the facility failed to readmit a resident (R1) to return to the facility after a transfer to the attached hospital emergency department (ED) for an increase in R1's behaviors for the third time in less than 24 hours. The facility would not allow R1 to return to the facility even though R1 was deemed medically stable, and the facility was able to meet the needs of the resident as identified by their facility assessment.