Lahser Hills Care Centre

In the surveyor’s words

From the most serious findings on record at Lahser Hills Care Centre, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 21, 2023

  This citation pertains to intake #MI00129778 This citation contains three Deficient Practice Statements (DPS). DPS #1 Based on interview and record review the facility failed to consistently monitor a resident in respiratory distress, notify the physician of ineffective interventions and failed to transfer the resident to a higher level of care for appropriate treatment for one (R312) of three residents reviewed for infection prevention and control, resulting in staff to not have completed and documented consistent respiratory assessments and monitoring once staff identified R312 with a low oxygen saturation rate of 72%, staff failed to inform the physician of the supplemental oxygen to not have been effective, and failed to transfer the resident to a higher level of care for further… […]

• Immediate jeopardy, isolatedF684Aug 13, 2021

  This citation pertains to Intake Number MI 544, MI 585, MI 710, MI 658 and MI 222 and has two deficient practices. Deficient Practice #1 Based on interview and record review, the facility failed to respond timely to changes in condition for one (R801) of three residents reviewed for changes in condition that included an unstageable pressure ulcer that developed and worsened in the facility and critical lab results that indicated the resident had an infection; failed to coordinate care between nursing staff and multiple medical practitioners; and failed to implement new interventions and treatments in a timely manner when a pressure ulcer was identified; failed to identify the worsening condition of the pressure ulcer; and failed to revise treatment and interventions in a timely manner when… […]

• Actual harm, isolatedF686Jun 5, 2025

  Based on observation, interview and record review, the facility failed to prevent pressure ulcer formation, document accurate skin assessments and implement interventions for one (R80) of three residents reviewed for pressure ulcers resulting in R80 acquiring a Stage 4 (full-thickness skin and tissue loss). Findings include: On 6/3/25 at 9:51 AM, R80 was observed lying in their bed. R80 was asked if they had any wounds or sores. R80 explained they had a couple wounds on their bottom. When asked if they had developed the wound at the facility or if they were present when they were admitted , R80 explained one developed at the facility. […]

• Actual harm, isolatedF686Dec 30, 2024

  This citation pertains to Intake MI00148859 Based on observation, interview and record review, the facility failed to prevent pressure ulcer formation, document accurate skin assessments, implement interventions and complete pressure ulcer wound care per physician orders for two (R903 and R904) of three residents reviewed for pressure ulcers resulting in R903 acquiring one Stage 4 (full-thickness skin and tissue loss) which became infected and required antibiotics and acquired a Deep Tissue Pressure Injury (DTPI - persistent non-blanchable deep red, maroon or purple discoloration) and R904 who aquired an unstageable wound to their coccyx. Findings include: R903 A complaint was filed with the State Agency (SA) that alleged in part, .the resident . has developed a wound on (their) buttocks . […]

• Actual harm, isolatedF689Sep 7, 2023

  This citation refers to Intake #MI00137826 Based on interview and record review, the facility failed to ensure a safe and proper transfer from the bed to Geri chair for one resident (R808) of two residents reviewed for falls/accidents, resulting in seven stitches over the left eye, two lumps (hematomas) on the forehead, bruising to the left side of their neck, bruising on the left side of their chest, pain, and a three-day hospital stay. Findings include: A Complaint was filed with the State Agency (SA) that alleged R808 was a two-person transfer in need of a Hoyer lift and was transferred by only one Certified Nursing Assistant (CNA) who used a sit-to-stand (a medical device that assists individuals with limited mobility in standing up from a seated position) and the resident fell during… […]