Admiral at the Lake, The

In the surveyor’s words

From the most serious findings on record at Admiral at the Lake, The, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 6, 2025

  Based on interview, and record review facility failed to perform accurate fall risk assessment for a resident with a known fall history, develop and implement post fall interventions to prevent future falls and failed to monitor, document, and send resident to hospital in a timely manner post fall incident for one resident (R2) out of four residents reviewed for accident and supervision. This failure led to R2 falling in the facility sustaining multiple acute fractures. Findings Include: R2's Minimum Data Set (MDS) dated [DATE] shows he is cognitively impaired. […]

• No harm, potential for more than minimal, widespreadF812Mar 5, 2026

  Based on observation, interview and record review the facility failed to label and date opened food stored in the refrigerator and freezer, failed to discard expired food, failed to use hair nets while working in the kitchen. Failed to store food off the floor. This failure has the potential to affect all residents that receive oral diets.Findings include:On 03/02/26 at 9:28am observed facility's walk-in refrigerator with open containers of mixed fruit, muffin mix, hamburger patties, [NAME] slaw, hot dogs, sliced American cheese, egg mix all with no open or discard date. […]

• No harm, potential for more than minimal, widespreadF880Mar 5, 2026

  Based on observation, interview and record review the facility failed to perform hand hygiene between passing dining trays, failed to clean multi use equipment after use for two residents (R2 and R11), failed to perform hand hygiene after caring for one resident (R6), failed to wear PPE (Personal Protective Equipment) while caring for one resident (R17) on EBP (Enhanced Barrier Precautions), failed to perform hand hygiene during resident ADL (activities of daily living) care for one resident (R20), failed to store clean and soiled linen in a way to prevent the spread of infection. This failure affected five residents (R2, R6, R11, R17, R20) and has the potential to affect all residents that reside in the facility. […]

• No harm, potential for more than minimal, widespreadF804Jan 24, 2025

  Based on observation, interview, and record review the facility failed to follow their policies and implement safe food preparation and services to ensure the food conserves a safe temperature. This failure has the potential to affect all residents that receive nutrition from the kitchen. Findings include: On 1/21/2025 at 9:38 AM, this surveyor reviewed facility dated 1/21/2025 titled Hot holding (main kitchen) temperature log does not document a temperature was taken for the breakfast food (scrambled eggs, scrambled eggs puree, breakfast meat, breakfast meat puree, oatmeal, oatmeal puree, cheese omelet, cheese omelet puree). On 1/21/2025 at 9:39 AM, V6 (Director of Culinary Services) states that it should be filled out before the food goes out. […]

• No harm, potential for more than minimal, widespreadF812Jan 24, 2025

  Based on observation, interview, and record review the facility failed to store and label food items in accordance with professional standards for food service safety and follow proper sanitation and food handling. This failure has the potential to affect all residents that receive nutrition from the kitchen. Findings include: On [DATE] at 9:53 AM in the refrigerator with V6 (Director of Culinary Services), was approximately 20 slices of cheese slices dated ,d+[DATE] use by ,d+[DATE], approximately 15 slices of turkey dated ,d+[DATE] use by ,d+[DATE], the tail end of cured Italian meat prepared [DATE] with use by [DATE]. A Three 5-pound containers of cottage cheese that expired on [DATE]. […]