Lake Park Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF686Apr 24, 2025

  Based on record review and staff, Nurse Practitioner, Orthopedic Nurse Practitioner, and Physician's interviews the facility failed to provide monitoring for skin breakdown under a leg immobilizer for 1 of 3 residents (Resident #1) reviewed for wound care. Resident #1 developed a stage 3 pressure ulcer to her right thigh which was found on 2/19/2025, and a pressure ulcer to the right ankle. On 3/18/25 the pressure ulcer to the right ankle was assessed as an unstageable pressure ulcer. Findings included: Resident #1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of a right femur fracture. […]

• Actual harm, isolatedF689Nov 3, 2023

  Based on record review, staff interviews, and family interview the facility failed to provide supervision to prevent accidents for a resident with a known history of falls, when Resident #1 was left unattended in the common area and had an unwitnessed fall. This occurred for 1 of 1 resident reviewed for accidents and resulted in the resident going to the hospital to receive 7 stitches to his face (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, lack of coordination, recurrent falls, dementia, and anxiety. A significant change Minimum Data Set for Resident #1 dated 8/15/23 revealed he was cognitively impaired. […]

• Actual harm, isolatedF697May 5, 2023

  Based on observations, record review, staff interviews, resident interview, and Physician interview the facility failed to administer scheduled pain medication after it was requested for a resident that was experiencing ten out of ten pain. This occurred for one of four residents reviewed for pain. (Resident #310) This failure resulted in Resident #310 experiencing her pain being off the charts and crying related to her pain. The findings included: Resident #310 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of the right knee, right knee replacement, right knee pain, and rheumatoid arthritis. A 5-day Minimum Data Set for Resident #310 dated 4/27/23 revealed she was cognitively intact with no behaviors. […]

• Actual harm, isolatedF725May 5, 2023

  Based on observations, record review, staff interviews, and resident interviews the facility failed to have sufficient nurse staffing to ensure residents received pain medication when needed. (Resident #310). The findings included: This citation is cross referenced to F697 B.) F697: Based on observations, record review, staff interviews, resident interview, and Physician interview the facility failed to administer scheduled pain medication after it was requested for a resident that was experiencing ten out of ten pain. This occurred for one of four residents reviewed for pain (Resident #310). This failure resulted in Resident #310 experiencing her pain being off the charts and crying related to her pain. […]

• No harm, potential for more than minimal, patternF583Oct 24, 2024

  Based on observations, record reviews and staff interviews, the facility failed to protect resident privacy by leaving an unattended resident roster with personal health information (PHI) on top of a medication cart in the hallway and visible to the public. This was for 1 of 3 medication carts (700 Hall Medication Cart) reviewed for privacy and confidentiality. This deficient practice had the potential of effecting 22 residents on the 700 hall (Resident #98, #12, #96, #54, #82, #90, #97, #57, #33, #204, #88, #203, #55, #99, #91, #13, #83, #7, #20, #51, #35, and #60). The findings included: A continuous observation was completed on 10/21/2024 from 8:40 AM to 9:02 AM of the 700 Hall Medication Cart. […]