Thrive of Lake County

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents that needed a Level 2 PASARR assessment received a Level 2 PASRR for 4 of 8 residents (R52,R130,R134,R97) reviewed for Pre-admission Screening and Resident Review in the sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident or his or her representative of their right not to sign the arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility and failed to explained the agreement to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands for 4 of 4 residents (R25, R83, R159 and R172) reviewed for arbitration agreements in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure R18's as needed psychoactive medication had a stop date for 1 of 5 residents (R18) reviewed for chemical restraints in the sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to ensure a current and accurate PASARR 1 screening (Preadmission Screening and Resident Review screening) was completed on a resident for 1 of 8 residents (R13) reviewed for PASARR I screenings in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide hand hygiene and nail care to a resident for 1 of 31 residents (R14) reviewed for activities of daily living (ADLs) in a sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion had orthotics (splints) in place for treatment of and/or prevention of contractures for 2 of 12 residents (R95, R14) reviewed for range of motion/restorative services in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to transfer a resident in a safe manner and failed to ensure fall interventions were in place to residents on high risk for falls to 3 of 31 residents, (R141, R82, R24) reviewed for safety in the sample of 31. The finding's include: 1. R141's facility assessment, dated 5/26/26, with BIMS (Brief Interview for Mental Status) of 14; R141 has no cognitive impairment. R141's Fall risk assessment, dated 6/6/26, shows R141 is high risk for falls On 6/8/26 at 9:50 AM, R141 said she had a fall last Saturday (6/6/26) after having a shower. R141 said she was about to be transferred to her bed when the staff helping her could not hold onto her. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, with a history of significant weight loss and continued insidious weight loss, received nutritional supplements as prescribed for 1 of 6 residents (R2) reviewed for weight loss in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's enteral (tube) feeding was administered as per physician order for 1 of 2 residents (R10) reviewed for tube feeding in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a peripherally inserted central catheter (PICC) line dressing was changed according to standard of care for 1 of 2 residents (R94) reviewed for PICC line care in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an insulin pen and an inhaler were dated upon opening, and failed to ensure medications were stored in a secure manner and not accessible to residents to 3 of 31 residents (R48, R56, R161) reviewed for medication storage in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was served the noon meal in the ordered form for 1 of 31 residents (R4) reviewed for diets in the sample of 31.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff wore the correct Personal Protective Equipment (PPE) when caring for residents on Enhanced Barrier Precaution (EBP) isolation room, which applies to 1 of 31 residents reviewed for infection control in a sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care was safely provided to 1 of 3 residents (R1) reviewed for falls in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was safely turned and positioned during incontinence care for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medication as ordered by a physician for 1 resident (R1), failed to ensure medications were stored in their original packaging prior to administration for 5 residents (R7,R8,R9,R10,R11). These failures apply to 6 of 8 residents reviewed for medications in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an injury of unknown origin to 1 of 3 residents reviewed for unknown origin in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to accurately bill and issue a refund for an overpayment to a resident in a timely manner for 1 of 3 residents (R1) reviewed for billing in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was supervised for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 4. This failure resulted in R1 falling and sustaining fractures to her pelvis.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's pain medications was provided for 1 of 2 residents (R133) reviewed for pain management in the sample of 32. These failures resulted in R133 experiencing unrelieved pain and was not unable to fully obtain restful sleep for three days.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dry goods were stored in a manner to prevent cross-contamination, serve food in a manner to prevent cross-contamination, and failed to properly sanitize the food preparation surfaces. These failures affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food at an appetizing temperature to the residents for 3 of 3 residents (R112, R80, R68) reviewed for appetizing food temperatures in the sample of 31 and 2 residents outside of the sample (R113, R79).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure contact isolation precautions were posted (R465), failed to ensure personal protective equipment was worn in enhanced barrier precaution rooms (R157, R16) and failed to change gloves during pericare (R80) to prevent cross contamination for 4 of 5 residents reviewed for infection control in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a resident's dignity during personal care. This applies to one of one residents (R66) reviewed for dignity in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to transfer a resident in a safe manner. This applies to one of eight residents (R66) reviewed for safety in the sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a dressing change and measurement of an IV PICC (a peripherally inserted central catheter) line's external catheter was completed for 1 of 1 resident (R15) reviewed for PICC lines in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility to ensure medications were administered as prescribed. There were 31 opportunities with 2 errors, resulting in a 6% error rate. This applies to 1 of 2 residents (R264) observed in the medication pass.

Inspectors wroteBased on interview and record review the facility failed to ensure treatments were completed as prescribed for a resident with an unstageable sacral pressure ulcer. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to immediately notify a power of attorney about the initiation of treatment for a pressure injury for 1 of 3 residents (R1) reviewed for notifications in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from physical abuse for 1 of 5 residents (R1) reviewed for abuse in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe environment for 2 of 5 residents (R1 and R2)reviewed for safety in the sample of 5.

Inspectors wrote3. R72's Wound Physician Progress note dated 1/17/24 documents she is a [AGE] year old female with a stage 4 pressure ulcer to the left lateral thigh measuring 11 cm (centimeters) x 4 cm x 3 cm. Necrotic and adipose tissue exposed, there is a large amount of sero-sangineous drainage. The treatment orders include to cleanse wound with normal saline, apply collagen, cover wound with 4x4 gauze and abdominal pad and cover with boarded gauze dressing, Change dressing as needed for soiling and saturation. R72's Physician Order Sheets dated January 2024 shows order dated 1/18/24 left lateral thigh: cleanse with normal saline and apply collagen and foam dressing (it does not include to apply the 4x4 gauze and abdominal pad). On 1/22/24 at 9:47 AM, R72 said she has a sore on her thigh and the dressing gets changed every three days. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have a process in place to discard medications, failed to ensure controlled substances were reconciled according to standards of practice, failed to ensure residents (R26, R139) were supervised during medication administration, and failed to ensure medications were re ordered from pharmacy as indicated for a resident (R11). These failures have the potential to effect all 163 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to fully submerge a pitcher, hotel pan, and food service container with a lid to ensure the items were sanitized to prevent foodborne illness. This has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who require extensive assist with activities of daily living received assistance with incontinence care and during meals/feeding. This applies to 9 of 32 residents (R118, R72, R124, R113, R89, R94, R107, R93, R3) reviewed for activities of daily living in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities and monitor behaviors for residents with a diagnosis of dementia. This applies to 6 of 8 residents (R15, R16, R48, R89, R90 & R135) reviewed for dementia care in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure controlled substances were secured and reconciled, failed to ensure expired medications were disposed of, failed to ensure the medication refrigerator was in proper working condition with a thermometer inside, and failed to ensure the medication rooms were free from excessive discharged /discontinued resident medications. This failure has the potential to effect all 43 residents residing in the Transitional Care Units (TCU) of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve a single #6 scoop of pureed baked mostaccioli to residents receiving a pureed diet. This applies to 13 of 13 (R38, R60, R49, R101, R15, R66, R104, R138, R67, R92, R89, R23, and R61) residents reviewed for pureed diets in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is positive for COVID-19 was isolated on droplet/contact precautions, failed to ensure staff wore the required PPE (Personal Protective Equipment) when entering a positive COVID-19 room, and failed to ensure staff changed their gloves during incontinence care in a manner to prevent cross contamination. This applies to 4 of 32 residents (R67, R142, R96, R9) reviewed for infection control in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's diet orders were followed and supervised as prescribed by the physician. This failure resulted in R106's diet orders not being followed by receiving bread and needing the Heimlich maneuver for choking on bread pudding. The facility also failed to ensure residents were supervised during meals who require close supervision. This applies to 2 of 32 residents (R106 & R17) reviewed for safety/supervision in the sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a residents urinary drainage bag below the level of her bladder for one of four residents (R96) reviewed for catheters in the sample of 32.

Inspectors wroteBased on interview and record review the facility failed to ensure psychotropic medications ordered as needed (PRN) had a duration/end date. This applies to one of six residents (R11) reviewed for unnecessary medication in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was served at an appetizing temperature for 5 of 5 residents (R2-R4, R6 and R10) reviewed for cold food in the sample of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure personal protective equipment (PPE) was properly worn to prevent the spread of COVID-19 for 1 of 4 residents (R8) reviewed for infection control in the sample of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a staff donned (Personal Protective Equipment) PPE when entering a COVID positive resident's room, failed to ensure doors were kept closed and signage were posted on the type of isolation on COVID 19 positive residents room to 21 residents (R8-R28) reviewed for infection control in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's prescribed medications were administered as ordered. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 28.

Inspectors wroteBased on interview and record review that facility failed to ensure a resident with pain received pain medication in a timely manner for 1 of 3 residents (R1) reviewed for pain management in the sample of 3.