Blue Lake Post Acute

In the surveyor’s words

From the most serious findings on record at Blue Lake Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 8, 2025

  Based on observations, a review of resident and facility records, interviews with staff, and a review of job descriptions and facility policies and procedures, the facility failed to protect the resident's right to be free from sexual abuse from a resident. This resulted in sexual contact for one resident who was unable to consent to sexual activity (Resident #1) of three residents reviewed for abuse. The facility failed to develop and implement interventions necessary to protect Resident #1 from sexual contact by Resident #2, who had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment, and who was independently ambulatory with the use of a cane. […]

• Immediate jeopardy, isolatedF610Apr 8, 2025

  Based on staff interviews, resident and facility record reviews, and a review of facility policies and procedures, the facility failed to thoroughly investigate sexual abuse for one (Resident #1) of three residents reviewed for abuse. Failure to investigate sexual abuse thoroughly, put the facility's female residents at a likelihood for suffering sexual abuse, which could result in serious psychosocial harm, which would diminish their self-worth and self respect. Immediate Jeopardy (IJ) at a scope and severity of J (isolated) was identified on April 7, 2025 at 3:50 p.m. On April 1, 2025, at 6:55 p.m., Immediate Jeopardy began. On April 8, 2025, at 6:15 p.m., the Administrator was notified of the IJ determination and was provided with Immediate Jeopardy Templates. […]

• Immediate jeopardy, isolatedF835Apr 8, 2025

  Based on staff interviews, resident and facility record reviews, and a review of job descriptions, the facility's administration failed to ensure that staff provided appropriate supervision to protect vulnerable residents from sexual abuse for one (Resident #1) of three residents reviewed for abuse. The facility administration failed to ensure that staff developed and implemented interventions necessary to protect Resident #1, who was unable to consent, from sexual contact by Resident #2. Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment, and was independently ambulatory with the use of a cane. […]

• Immediate jeopardy, isolatedF867Apr 8, 2025

  Based on staff interviews, resident and facility record reviews, and a review of facility policies and procedures, the facility's Quality Assessment and Quality Assurance Committee (QAA) failed to develop and implement appropriate plans of action to correct identified quality deficiencies, particularly those that caused adverse outcomes. This resulted in a lack of improvement of their systems and processes. This failure contributed to the sexual abuse of one (Resident #1) out of three residents reviewed for abuse. It also placed all other vulnerable female residents at a likelihood for serious adverse outcomes related to potential sexual abuse from Resident #2. […]

• No harm, potential for more than minimal, widespreadF727Apr 10, 2026

  Based on interviews and record review, the facility failed to designate a full time Director of Nursing (DON) as required, leaving the position vacant from 1/19/26 through 4/5/26. The findings include:During the entrance conference on 4/6/26 at 9:40 a.m., the Administrator was asked to identify the facility's DON. He named the current DON and stated that today, 4/6/26, was her first day back. He confirmed she had resigned in January 2026 and returned to the position on 4/6/26.On 4/7/26 at 8:00 a.m., the DON was interviewed and was asked who had been designated as the facility's DON from the time she resigned in January 2026 until her return on 4/6/26. […]