Scott Lake Health and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure medications were stored in accordance with current professional standards for 6 of 6 medication carts, 2 of 4 medication storage rooms, and central supply storage.1. An observation on 4/21/2026 at 3:30 P.M. of the 100 Hall Top Medication Cart revealed:In the top drawer was one loose ciprofloxacin pill; the pill did not have a resident name. In the top drawer was a container of cholestyramine powder that expired on 3/30/2026. The bottom drawer of the medication cart contained 11 safety syringes that expired on 2/3/2026. An interview on 4/21/2026 at 3:35 P.M. with Staff M, Registered Nurse (RN) was conducted. Staff M, RN verified the medications in 100 Hall Top Medication Cart were expired and she said the medications should have been removed. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure call lights were within reach for eight residents (#63, #115, #61, #7, #98, #124, #82, and #95) out of nine residents sampled for call lights.

Inspectors wroteBased on observations, interviews and record reviews the facility failed ensure Preadmission Screening and Resident Review (PASRR) was accurate for one (Resident #10) out of two Residents sampled for PASRR. Review of Resident #10's admission record revealed the resident was admitted on [DATE]. The record included diagnoses not limited to schizoaffective disorder, depressive type (onset 8/10/2022), generalized anxiety disorder (onset 8/10/2022), major depressive disorder, recurrent, moderate (10/03/2022), and insomnia (onset 7/11/2025). Review of Resident #10's Minimum Data Set (MDS), dated [DATE] for Medications, revealed the resident is taking an antidepressant and antipsychotic regularly. Review of Resident #10's psychiatric notes dated 4/15/2026 revealed Resident #10 had a diagnosis of schizoaffective disorder, depression, anxiety, and insomnia. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective resident call system in one room (113) of four rooms sampled for call light functioning.

Inspectors wroteBased on interview and record review, the facility failed to personalize resident care plans leaving Certified Nursing Assistants (CNAs) to choose between one- or two-person assistance transfers for two residents (#1 and #2) of three residents sampled. Failure to develop, revise and implement personalized transfer care plans puts residents at risk for falls. Findings Included: During an observation made on 10/23/2025 at 9:45 a.m., Resident #1 was observed in a common area, sitting up in their wheelchair in front of the television. Resident #1 did not respond to the interview. During a telephone interview on 10/23/2025 at 10:33 a.m., with Staff A, CNA, The staff member said regarding the shift on 10/09/25, I gave resident #1 a shower and was in her room putting her into her Geri chair . I was using a Hoyer Lift Staff A stated there was another CNA in the room with her. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from neglect related to medications not being reconciled and accurately transcribed, not reporting abnormal lab values and abnormal blood pressures to a provider for one resident (#1) out of three residents reviewed. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 8/22/25. The findings of Immediate Jeopardy were determined to be removed on 10/1/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm.

Inspectors wroteBased on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure the nursing staff was competent to reconcile hospital discharge medication orders, blood glucose levels were monitored for a diabetic resident, or recognize and respond to elevated blood pressures and abnormal lab results for one resident (#1) out of three residents reviewed. This failure created a situation that resulted in a worsened condition to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 8/22/25. The findings of Immediate Jeopardy were determined to be removed on 10/1/2025 and the severity and scope was reduced to a D after verification of removal of immediacy of harm.

Inspectors wroteBased on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure one resident (#1) of three reviewed for new admission orders was free from significant medication errors as evidenced by the resident not receiving the correct medications order upon admission. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 8/22/25. The findings of Immediate Jeopardy were determined to be removed on 10/1/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the medication error rate was less than 5.00%. Twenty-two medication administration opportunities were observed, and six errors were identified for two (#2 and #3) of two residents observed. These errors constituted a 27.27% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to notify the attending physician or Hospice on a change of condition for one (#1) of one resident sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and homelike environment for three (200, 300, 400) of four units related to: 1. heavy dust and debris build up on package terminal air conditioner (PTAC) unit filters in 17 resident rooms (415, 413, 412, 411 410, 409, 408, 404, 403, 402, 401, 213, 211, 209, 206, 202, 201) of 21 resident rooms, 2. bathroom shower stalls with rubber flooring strips not maintained and not secured to the floor in eight resident bathrooms (414, 405, 213, 211, 209, 206, 202, 201) of 11 resident bathrooms, 3. commode devices rusted and with paint chipped away, and a commode loose and a chipped tank lid in two resident bathrooms (312, 309), and 4. [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Reviews (PASRR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for nine (Residents #41, #21, #12, #14, #13, #90, #108, #103, and #87) of nine residents sampled for PASRRs

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and 23 errors were identified for two (Residents #84 and #89) of three residents observed. These errors constituted a 76.6% medication error rate. Findings Included: On 11/15/23 at 10:08 a.m. an observation of medication administration with Staff I, Registered Nurse (RN) was conducted for Resident #89. Staff I dispensed the following medications: -Amiodarone HCL 100 mg one tablet -Carbidopa/Levodopa 10 milligram (mg)/ 100 mg two tablets -Claritin 10 mg one tablet -Clopidogrel Bisulfate 75 mg one tablet -Tamsulosin 0.4 mg one tablet -Spironolactone 50 mg one tablet -Metoprolol 25 mg one tablet -Lasix 40 mg tablet one tablet -Eliquis 2.5 mg one tablet -Aspirin 81 mg DR one tablet On 11/15/23 at 10:36 a. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to properly secure medications in two of three medication carts, and for two (Residents #42 and #11) of 27 sampled residents in accordance with professional standards

Inspectors wroteBased on observation, staff interview, and facility record review, the facility failed to ensure the kitchen and kitchen equipment were sanitary and with food free from cross contamination related to: 1. Two large sheet pans, which had seven to ten individualized plates of cakes on them, were shelved directly below a tray of defrosting raw red meat. The meat had dripped and pooled with blood on the plates of cakes; 2. One of One walk in freezer was observed with open food items exposed and frosted; 3. One of one reach in refrigerator/freezer unit was observed with open food items exposed and frosted; and 4. Staff from outside vendors not wearing proper hair and beard restraints when around food preparation and food cooking areas.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident #12) of 30 residents in hall 400, received care in accordance with professional standards of practice related to a change in condition (CIC).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure one (Resident #2) of six resident were free from accidental hazards as evident by the identification of a heating pad in use by the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and storage of controlled medications in one of three medication carts inspected and in one of two medication storage rooms inspected.

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to provide appropriate monitoring of psychotropic medication use for 1 (Resident #1) of 5 residents sampled for unnecessary medications.

Inspectors wroteBased on an interview with the Administrator and the Director of Nurses, the facility failed to implement their Quality Assurance Program for three (Residents #8, #10, and #11) of three sampled residents, as evidence by failure to audit staff documentation of behaviors and side effects of psychotropic medications according to the plan of correction.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to honor resident preferences for use of assistive devices for 1 (Resident #100) of 32 residents sampled for resident choices.

Inspectors wroteBased on interview and record review the facility failed to provide timely response to concerns voiced by the resident council group.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide activities of daily living (ADL's) for 1 (#35) of 32 sampled residents related to nail care.

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to act upon a pharmacy recommendation in a timely manner for 1 (Resident #1) of 5 sampled residents for unnecessary medications.