Lake Forest Place

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 27, 2025

  Based on observation, interview and record review the facility failed to ensure a safe resident transfer and failed to ensure incontinence care was provided in a safe manner to prevent a fall. This failure resulted in R1 falling from bed during incontinence care and sustaining a femur fracture. This applies to 2 of 3 residents (R1 and R2) reviewed for safety in the sample of 3. The findings include: 1. R1's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired, her vision is highly impaired, she is always incontinent of urine and stool, weighs 180 pounds and is dependent (Helper does all of the effort. Resident does none of the effort to complete the activity) for rolling left and right. On 2/26/25 at 11:24 AM, R1 was laying in bed. […]

• Actual harm, isolatedF689Mar 8, 2023

  Based on interview and record review the facility failed to ensure fall risk interventions were in place for a resident (R27) at risk for falls with a history of falls. This failure contributed to R27 falling and sustaining a impacted and comminuted left femur fracture and a dislocated left knee. This applies to 1 of 13 residents reviewed for safety in the sample of 13. The findings include: R27's face sheet shows she has diagnoses including: history of falling, unsteadiness on feet, need for assistance with personal care, dizziness and reduced mobility. R27's 10/24/23 fall risk assessment shows she is at high risk for falls. […]

• Actual harm, isolatedF689Feb 23, 2022

  Based on interview and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining transverse tibial and fibular fractures. The findings include: R1's Minimum Data Set (MDS) dated [DATE] shows R1 is severely cognitively impaired and dependent of two staff for transfers and bed mobility. This same MDS shows R1 has impairment on both sides of her upper and lower extremities. The facility's Incident and Accident Report dated 1/26/22 shows R1 is [AGE] year, has diagnoses of Alzheimers disease, history of a [CONDITION(S)], seizures, and hospice, is non-ambulatory, and a total body lift with two assist for transfers. […]

• No harm, potential for more than minimal, widespreadF812Dec 12, 2024

  Based on observation, interview, and record review the facility failed to ensure dishes were washed in a manner to prevent cross-contamination and failed store thickener in a manner to prevent cross-contamination. This affects all 44 residents residing in the facility. The findings include: The facility's CMS 671 Form dated 12/10/24 shoed there were 44 residents residing in the facility. 1. On 12/10/24 at 10:08 AM, the surveyor, V3 (Dietitian), V4 (Director of Dining Services), and V8 (Dietary Manager) returned to the main kitchen. The dishwashing area was inside the door, to the left. The dishwashing station was a small square shaped area, with an opening to enter the area. The dirty dishes were stacked to the left of the dishwasher and directly across the area, from the dishwasher. […]

• No harm, potential for more than minimal, isolatedF689Jun 3, 2026

  Based on observation, interview, and record review the facility failed to ensure R1, who is dependent on the staff for bed mobility, did not fall out of bed while the staff was providing care for 1 of 3 residents (R1) reviewed for falls in the sample of 3.The findings include:On 06/03/2026 at 10:29AM, R1 was lying in the bed on an air mattress.On 06/03/2026 at 10:29AM, R1 stated, the nurse was changing me. I was lying on the edge of the bed, then she grabbed ahold of the sheet underneath me, she pulled it out and it shot me over the side. She was alone, she should have had another staff member, usually there are two assisting me in bed. […]