Springs at Lake Pointe Woods

Inspectors wroteBased on observations, review of facility's policy and procedure, and staff interviews, the facility failed to store and distribute food in accordance with professional standards for food service safety. This has the potential to affect 91 residents who consume the food made on the premises. The findings Included:Review of the facility policy on Food Receiving and Storage dated 6/2025 revealed that all foods stored in the refrigerator or freezer will be covered, labeled and dated. On 4/20/26 at 9:35 a.m., observations during the initial tour of the kitchen revealed:The following food items in the reach in refrigerator were not date-marked to indicate when the food must be consumed or discarded: 5 Apple Juice cups; 12 Cranberry Juice cups; 23 Orange Juice cups; a plate of tomato slices; a dish of an unknown white food item; a cup of fresh fruit; a container of Oat milk. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure garbage and refuse were properly contained in dumpsters and failed to ensure the surrounding area was maintained in a sanitary condition, free of trash and debris.

Inspectors wroteBased on observations, record review, review of facility policies and procedures, residents and staff interviews, the facility failed to ensure that 2 (Residents #11 and #74) of 3 residents reviewed for non-pressure wounds received appropriate care and services in accordance with physician's orders. The facility failed to ensure that 1 (Resident #48) of 3 residents reviewed had preventive measures in place to prevent new skin injuries.

Inspectors wroteBased on observation, review of facility's policy and procedure and staff interviews, the facility failed to provide necessary repair and store residents' personal care items in a sanitary manner in 7 (Rooms 101, 104, 106, 107, 108, 110 and 111) of 17 rooms of the [NAME] Unit observed.

Inspectors wroteBased on observations, record review, review of facility's policy and procedures, and staff interviews, the facility failed to implement the comprehensive person-centered care plan to meet the needs for communication for 1 (Resident #5) of 3 residents reviewed for implementation of care plan interventions.

Inspectors wroteBased on observation, review of clinical records and resident and staff interviews the facility failed to provide the necessary care to maintain personal hygiene for 2 (Resident #86 and #56) of 5 residents who required staff assistance with activities of daily living (ADLs).

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to ensure the safe storage of medications for 3 (Residents #56, #24, and #97) of 3 residents observed with unsecured medications at the bedside.

Inspectors wroteBased on record review, review of facility's policies and procedures and staff interviews, the facility failed to protect the resident's rights to be free from neglect by failing to follow safety precautions specified in the care plan to prevent avoidable accident with injury for 1 (Resident #1) of 3 dependent residents reviewed.

Inspectors wroteBased on record review, review of facility's policies and procedures and staff interviews, the facility failed to protect the resident's rights to be free from accidents by failing to follow safety precautions specified in the care plan resulting in an injury for 1 (Resident #1) of 3 dependent residents reviewed.

Inspectors wroteBased on record review, review of the facility's policies and procedures, and staff interviews, the facility failed to provide adequate supervision to prevent unsafe wandering and elopement for 1 (Resident #1) of 1 newly admitted cognitively impaired, confused resident exhibiting exit seeking behaviors. On 8/20/24 shortly after 4:15 a.m., Resident #1 who was confused, wandered and had documented exit seeking behaviors walked out of the facility through the front lobby. Staff was not aware of the resident's exit until 8/20/24 at 4:40 a.m. Resident #1 walked approximately half a mile through the parking lot, down a private road with a nearby unfenced pond, to a busy four lane main road. Resident #1 could have been hit by a car, assaulted, or fallen into the pond and drowned. [...]

Inspectors wroteBased on record review and interview, the facility failed to protect the right to be free from abuse for 1 (Resident #2) of 5 residents reviewed for abuse.

Inspectors wroteBased on observation interview and record review the facility failed to maintain a comfortable safe temperature within the facility.

Inspectors wroteBased on record review, staff interviews, and review of facility policy the facility failed to ensure the accuracy of a Pre-admission Screening and Resident Review (PASARR), and make the necessary corrections for 1(Resident #73) of 2 residents reviewed for PASARR.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide adequate supervision prevent falls for 2 residents (#9 and #18) of 3 residents reviewed for falls.

Inspectors wroteBased on record review, staff interview, and observation the facility failed to maintain an indwelling catheter in a safe and sanitary manner for 1(Resident #82) of 1 resident sampled with an indwelling catheter. This has the potential to cause injury and urinary tract infection. The facility policy Catheter Care, Including Drainage Bag Care /Maintenance documented the purpose of the policy: To provide safe and proper care of the resident with an indwelling urinary catheter. To minimize the risk of bladder infection. Procedure #8 documented: Position the drainage bag below the level of the residence bladder. Secure to the bed or wheelchair in such a manner that neither the bag nor the spigot touches the floor. Review of Resident #82's clinical record revealed a physician order for an indwelling catheter (tube inserted into the bladder to drain urine) for comfort at end of life. [...]

Inspectors wroteBased on observation, review of facility policy and procedures, record review, and staff interview, the facility failed to provide oxygen therapy, in accordance with physician orders, for 1 (Residents #82) of 1 resident reviewed for oxygen therapy. The facility also failed to have a system to maintain CPAP (continuous positive airway pressure therapy) and BIPAP (bi-level positive airway pressure therapy) machines in a sanitary manner for 2 (Resident #27 and #248) of 2 residents who use a CPAP/BIPAP machines (helps you breathe more easily when you sleep). This has the potential to cause respiratory infection.

Inspectors wroteBased on observation, review of facility policy and procedures and staff interviews, the facility failed to ensure insulin was properly dated when opened and stored on one (1) of three (3) medication carts observed. Without an open date on the medications there was no way to know when it would expire. The facility also failed to ensure expired medications were removed and disposed of in one (1) of two (2) medication rooms observed.

Inspectors wroteBased on record review and staff interview, the facility neglected to protect the resident's right to be free from neglect. The facility failed to provide physician ordered treatment of pressure ulcers for 1 (Resident #244) of 3 sampled residents surveyed for prevention and treatment of pressure ulcer.

Inspectors wroteBased on observation, record review and interview, the facility the facility failed to maintain an effective water management program to minimize the risk of outbreak of water borne pathogens.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to ensure they provided an ongoing program to support residents in their choice of activities which are designed to meet the resident's interests and support the resident physical, mental and psychosocial well-being for 1 (Residents #38) of 2 residents reviewed for involvement in the activity program. The lack of an ongoing activity program could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, record review, staff and resident interviews, the facility failed to ensure 1 resident (Resident #35) of 4 residents who entered the facility with an indwelling catheter was assessed for appropriate diagnosis and removal of the catheter.