Lake Forest Senior Living at Hot Springs Village

In the surveyor’s words

From the most serious findings on record at Lake Forest Senior Living at Hot Springs Village, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Sep 26, 2024

  Based on observation, interview, record review and facility policy review, the facility failed to follow residents request to initiate resuscitative measures for one (Resident #1) of five residents who had a full code status. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.24 (Quality of Life) at a scope and severity of J. The IJ began on [DATE] at approximately 7:40 PM when Resident #1 became unresponsive in - the resident's room. No action to perform cardiopulmonary resuscitation (CPR) was taken by facility staff. […]

• No harm, potential for more than minimal, widespreadF812Jun 12, 2024

  Based on observation, record reviews and interviews, the facility failed to ensure serving items were properly handled, hand sanitation was utilized, the kitchen was free from buildup of unknown substances that had the potential to cross-contaminate food items to be served, equipment was in safe and useable state, open food items were properly closed or sealed and had an open date, food items were not expired. The findings are as follows: On [DATE] at 10:35 AM, the following observations were made during the initial kitchen tour: The right side of the floor water drain grate was broken in 2 pieces. The larger piece inside the floor drain grate were covered in a brownish unknown substance with paint missing. […]

• No harm, potential for more than minimal, patternF583Jun 12, 2024

  Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to secure residents private health information on facility computers to prevent unauthorized sharing of electronic medical records (EMR), by leaving the EMR open in the hallway without staff present for 1 (Residents #5) of 16 sampled residents who were reviewed for protection on the electronic medical record. Findings include: A review of a facility policy titled, HIPAA (Health Insurance Portability and Accountability Act) Assigned Security Responsibilities- Enterprise, dated 04/11/2019, indicated, Confirming that Sanford's ePHI (electronic personal health information) receives reasonable and appropriate safeguards to protect its confidentiality,… […]

• No harm, potential for more than minimal, patternF689Jun 12, 2024

  Based on observations, interviews, and record review, the facility failed to ensure harmful chemicals, nail trimmers, and razors were stored securely to promote resident safety for 1 (Resident #135) of 1 sampled resident reviewed for accidents and hazards. Findings include: On 06/12/2024 at 4:59 PM, the Administrator stated the facility did not have a policy for chemical storage/hazards. A review of the Medical Diagnosis List, indicated the facility admitted Resident #135 with diagnoses that included unsteadiness on feet, difficulty in walking, not elsewhere classified, acute kidney failure, aftercare following joint replacement surgery. […]

• No harm, potential for more than minimal, patternF880Jun 12, 2024

  Based on observations, interviews, and record review, the facility failed to perform proper hand hygiene during resident care for 1 (Resident #23) of 1 sampled resident reviewed for tube feeding. Findings include: 1. A review of a facility policy titled, Hand Hygiene- Enterprise dated 03/29/2022, indicated, Hand Hygiene: a general term that applies to either handwashing or applying hand sanitizer. Handwashing includes washing hands with soap and water. Hand sanitizer involves using a waterless antiseptic agent. All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control practices. All employees in patient care areas (unless otherwise noted in their policy) will adhere to the 4 moments of hand hygiene and 2 zones of hand hygiene. 1. […]