Ecumen Lakeshore

In the surveyor’s words

From the most serious findings on record at Ecumen Lakeshore, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 13, 2024

  Based on observation, interview, and document review the facility failed to ensure dishwasher temperatures were maintained or implement other strategies to effectively sanitize dishware and utensils to reduce the risk of foodborne illness. This had potential to affect 56 residents residing in the nursing home along with staff and visitors who consume meals from the main production kitchen. Findings include: During observation on 6/13/24 at 8:43 a.m., culinary aide (CA)-A was washing morning dishes. The dishwasher monitoring system was flashing red and showed a low rinse temperature at 140 degrees Fahrenheit (F). The thermometer on the dishwasher also indicated 140 degrees. […]

• No harm, potential for more than minimal, widespreadF755Apr 15, 2021

  Based on observation, interview, and document review, the facility failed to ensure the emergency kits were tracked to prevent potential theft and diversion of medications. This had the potential to affect all 45 residents residing in the facility. Findings include: On 4/14/21, at 1:52 p.m. a tour of the medication storage room on the first floor was conducted with registered nurse (RN)-C. The emergency medication kit (e-kit) was in a locked cupboard and had a green plastic numbered security lock. RN-C stated two nurses signed out medications from this e-kit when a medication was ordered and the pharmacy was closed. -at 2:38 p.m. RN-D was interviewed. RN-D stated the e-kit contained narcotic medications. RN-D stated staff do not verify the plastic lock number on a routine basis. […]

• No harm, potential for more than minimal, patternF943Apr 15, 2021

  Based on interview and document review, the facility failed to ensure 7 staff (RN-B, LPN-A, NA-D, NA-E, SW-A, A-A, NA-E, and NA-C) received annual training for vulnerable adult (VA) abuse prevention and reporting. Findings include: Review of the facility abuse training records indicated: -Registered nurse (RN)-B was hired on 7/2/19, and completed only one of the Abuse and Neglect module in 2020. - Licensed practical nurse (LPN)-A was hired on 8/13/19, and did not complete either of the abuse modules in 2020. -Nursing assistant (NA)-D was hired on 10/15/19, and did not complete either of the abuse modules in 2020. -NA-E was hired on 1/22/90, and did not complete either of the abuse modules in 2020. […]

• No harm, potential for more than minimal, isolatedF641Aug 7, 2025

  Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 1 resident (R8) reviewed for MDS accuracy.Findings included:The CMSA Long-Term Care Facility Resident Assessment Instrument (RAI) 3. User Manual, dated 10/2023, identified each section of the MDS along with various instructions how to code and/or complete them. The section labeled, Section F: Preferences for Customary Routine and Activities. This section had the intent to obtain information regarding the resident's preferences for her daily routines and activities.R (8)'s annual MDS dated [DATE] indicated, R8 had memory problems, had no delusions or hallucinations, and did not reject cares. […]

• No harm, potential for more than minimal, isolatedF582Sep 8, 2023

  Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 1 of 2 residents (R14) reviewed whose Medicare A coverage ended and remained in the facility. Findings include: R14's Centers for Medicare and Medicaid Services (CMS)-10123 dated 5/1/23, identified a Medicare last covered day (LCD) of 5/3/23. R14's undated Census Records form identified on 5/4/23, R14's payer source changed from Medicare Part A to Private Pay, and R14 remained in the facility. R14's medical record lacked evidence a SNFABN was provided to explain the estimated cost per day or provide rationale of the extended care services or items to be furnished, reduced, or terminated. […]