Lake Park of Madison Nursing and Rehabilitation Ce

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 31, 2021

  Based on observation, staff interview and record review, the facility failed to ensure 1 of 3 vulnerable residents at risk for elopement (Resident #1) was not able to exit the building unsupervised via a window on 2/09/21. Additionally, on 3/29/21, the facility failed to ensure windows and all entry/exit doors were secured to prevent subsequent elopements for 1 of 2 current residents at risk for elopement (Residents #2). The facility's failure to prevent an elopement and eliminate potential hazards placed 2 residents at a likelihood of serious injury and death. […]

• Immediate jeopardy, isolatedF867Mar 31, 2021

  Based on observation, staff interview and record review, the facility Quality Assurance and Performance Improvement (QAPI) process failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to resident elopement that occurred on 2/09/21 (resident #1). The facility's failure to follow the QAPI process may prevent the facility from correcting and improving their systems to ensure resident safety and prevent serious harm for residents at risk for elopement (Resident #2). The facility's failure to prevent an elopement and eliminate potential hazards placed 2 (Residents #1 and #2) residents at a likelihood of serious injury and death. […]

• No harm, potential for more than minimal, patternF919Feb 25, 2021

  Based on observation, interview, and record review, it was determined the facility failed to ensure a functional resident call system on the entire East Wing of the facility. The findings include: On 2/22/21 beginning at approximately 11:20 AM, a tour of the 100, 200, and 300 hallways was conducted. These hallways were noted to have 53 residents with various levels of dependency. During the tour, residents and staff reported the call bell system for both resident rooms and resident bathrooms was not functional. Staff reported the situation had been ongoing for several months. Residents were observed to have actual bells in their rooms to use instead, however there were no bells or alternate call/alert system for resident bathrooms noted. […]

• No harm, potential for more than minimal, isolatedF584Oct 31, 2024

  Based on observations and interviews, the facility failed to maintain a clean and sanitary environment in the shower rooms, soiled utility rooms, and laundry room (photographic evidence obtained). The findings include: A tour of the facility was conducted on 10/31/24 at 11:00 AM with the facility's Administrator and Maintenance Director. During this tour, the following areas of concern were identified: In the East Side Shower Room, 3 of 3 shower stalls were observed to have a large build-up of dark matter on the walls, grout lines, and floors. In the [NAME] Side Shower Room, 2 of 3 shower stalls were observed to have a large build-up of dark matter on the walls, grout lines, and floors. In the East Side Soiled Utility Room, 2 garbage cans were observed without lids. […]

• No harm, potential for more than minimal, isolatedF636Jul 20, 2023

  Based on interviews and record review, the facility failed to complete a comprehensive assessment for 1 of 5 residents sampled for nutrition. (Resident #54) The findings include: A review of Resident #54 electronic medical record revealed the following recorded weights: 2/1/23- 113.8 pounds (lbs.) 3/4/23- 111.6 lbs. 4/5/23- 106.0 lbs. 5/4/23-106.2 lbs. 6/4/23- 102.4 lbs. 7/5/23- 94.6 lbs. These weights indicate that Resident #54 had a weight loss of 16.9% of the resident's total body weight within a six month time frame. […]