Hidden Lake Health Care Center

In the surveyor’s words

From the most serious findings on record at Hidden Lake Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Oct 28, 2022

  Based on observation, interview, and record review, the facility failed to follow proper infection control practice when they failed to implement their water management program to prevent the spread of waterborne pathogens, such as Legionella. The facility failed to sanitize shared medical equipment between resident use, follow proper infection control practices when handling resident laundry, and offer residents hand hygiene prior to meal service. This deficient practice has the potential to affect all residents who reside in the facility. The census was 51. 1. […]

• Actual harm, isolatedF689May 21, 2026

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #18) received adequate supervision and care to prevent accidents when one Certified Nurse Aide (CNA) failed to ensure two staff were present to assist during personal care, in accordance with the resident's care plan. While providing care, the CNA rolled the resident off the bed and onto the floor, resulting in the resident sustaining a fractured arm. The sample was 11. The census was 63. The Administrator was notified on 5/21/26 of the past non-compliance, which occurred on 5/8/26. The facility provided in-service training for all staff regarding the facility's resident bed mobility, transfer, and care policies. The deficiency was corrected on 5/8/26. […]

• Actual harm, isolatedF689Aug 30, 2024

  Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance to prevent accidents for two residents. Staff failed to follow safe practices, respond to request for additional assistance and be aware of the resident's surroundings for one resident (Resident #1) when moving the resident in the bed. The resident fell off the raised bed, onto the floor, sustaining three spinal compression fractures (break in a vertebra (spinal bone) that then collapses), a tooth avulsion (complete displacement of a tooth from its socket due to trauma) and a contusion (bruise) of the face. Staff also failed to complete a safe gait belt (assistive device used to help prevent falls during transfers) transfer for one resident (Resident #2). […]

• Actual harm, isolatedF684Aug 19, 2024

  Based on interview and record review, the facility failed to thoroughly and accurately assess, document, and notify the physician of a change in condition sustained by two of 14 sampled residents (Residents #44 and #36) and one closed record (Resident #306). Resident #44 had a diagnosis of congestive heart failure and history of fluid retention. The facility failed to monitor and report the resident's weight gain and respiratory changes. Resident #44 was transported to the hospital and administered intravenous Lasix (diuretic). Resident #306 experienced symptoms of confusion and inability to use a motorized wheelchair. The facility received orders for lab work on 6/6/24 and critical lab results were sent to the facility on [DATE]. […]

• Actual harm, isolatedF686Aug 19, 2024

  37672 Based on observation, interview and record review, the facility failed to ensure one resident who readmitted to the facility with an identified Stage II pressure wound (a partial thickness loss of the skin epidermis and dermis that appears as an open wound or blister) to the coccyx (tailbone) did not develop worsening or additional skin wounds. The facility failed to conduct re-admission wound measurements, transcribe hospice wound care orders, and notify the physician of the wound. As a result, the wound the resident had on admission got larger and appeared to have slough (moist dead tissue) that developed which is consistent with a Stage III pressure injury (full tissue loss) (Resident #9). The sample size was 14. […]