Lake Mariam Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lake Mariam Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600May 17, 2024

  Based on observations, interviews and record reviews, the facility failed to protect residents' right to be free from sexual abuse by a resident. Three residents (#2, #4, #8) of five with physician-signed lack of capacity to consent documents experienced sexual abuse in the facility. Resident #1 had a documented history of inappropriately touching and attempting to kiss staff beginning August 25, 2023. The facility did not respond with interventions that prevented sexual abuse from occurring to vulnerable residents. On 9/5/23 Resident #4 was discovered naked in their room with another resident (Resident #1). On 3/29/24 staff observed a resident (Resident #7) removing his hand from Resident #8's pants. On 4/15/24 during the 3:00 p.m. […]

• Immediate jeopardy, isolatedF684Mar 12, 2026

  Based on interviews and record reviews, the facility failed 1) to report abnormal radiology results to the provider and complete an assessment and change in condition for a resident with respiratory distress for one resident (#7) out of six residents sampled, 2) to ensure laboratory orders were entered in the electronic laboratory (lab) portal and completed as ordered for two residents (#7, #1) out of six residents sampled and 3) to ensure timely administration of an antibiotic for one resident (#1) out of three residents sampled. Resident #7's laboratory orders were not completed as ordered, the abnormal radiology results were not reported to the doctor, and an assessment and change in condition were not completed and Resident #7 suffered a cardiac arrest. […]

• Immediate jeopardy, isolatedF773Mar 12, 2026

  Based on interviews and record reviews, the facility failed to ensure laboratory orders were entered properly in the electronic medical record and electronic laboratory (lab) portal, for four (#7, #1, #8, #9) out of six residents sampled.Resident #7's labs were not completed as ordered and Resident #7 suffered a cardiac arrest This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the scope and severity was reduced to a D after verification of removal of immediate jeopardy. […]

• Immediate jeopardy, isolatedF600Aug 18, 2023

  Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Staff Development Coordinator, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility neglected to ensure one resident (#1), at risk for elopement, was provided with services related to the resident's known cognitive deficits and history of wandering out of 47 residents sampled. The facility nursing staff neglected to ensure the safety of Resident #1; between approximately 9:00 PM on 7/18/2023 and 4:00 AM on 7/19/2023, Resident #1 ambulated from his room on the second floor of the facility, passed the unit nurse's station, and walked approximately 40 feet to the facility elevator. […]

• Immediate jeopardy, isolatedF689Aug 18, 2023

  Based on observations, interviews with the nursing staff, Nursing Home Administrator, the Director of Nursing, the facility's Staff Development Coordinator, the facility's Medical Director, the resident's family member and review of the resident's medical record and facility policies, the facility failed to ensure one resident (#1) of 47 residents at risk for elopement, was provided with supervision and services related to the resident's known cognitive deficits and history of wandering before admission to the facility. […]