Lake Regional Health Systems

In the surveyor’s words

From the most serious findings on record at Lake Regional Health Systems, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Aug 23, 2022

  Based on observation and interview, the facility staff failed to store food in a manner to protect it from potential contamination and out-dated use. The facility census was seven. 1. Review of the facility's Storage of Food-Labeling, Storing and Dating policy, dated 11/09/16, showed: -Cold items are put into storage containers, covered, labeled and dated with and in and discard date before they are refrigerated. -Once a week, the walk-in and all refrigerators are thoroughly cleaned. Any any time, any food dated longer than seven days is discarded. Freezer leftovers are not kept longer than a year. -Manufacturers recommended storage dates are used when storing food. […]

• No harm, potential for more than minimal, patternF607Jan 18, 2024

  Based on interview and record review, facility staff failed to check the Certified Nursing Aide (CNA) Registry to ensure staff did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse and/or neglect) in accordance with the facility policy for six current employee's ([NAME] Patient Care Technician (PCT) I, student nurse intern J, Licensed Practical Nurse (LPN) K, housekeeper L, PCT M, and Health Unit Coordinator N out of seven sampled staff. The facility census was 5. 1. […]

• No harm, potential for more than minimal, patternF700Jan 18, 2024

  Based on observation, interview, and record review, facility staff failed to conduct or complete entrapment assessments and measurements to identify areas of possible entrapment prior to the use of bed rails on admission for four residents (Resident #255, #256, #257, and #258) out of five sampled residents. The facility census was 5. 1. Review of the facility's policies showed the facility did not provide a policy for entrapment assessments. 2. Review of Resident #255's medical record showed the record did not contain a completed entrapment assessment. Observation on 01/17/24 at 4:18 P.M., showed the resident in bed with bilateral bedrails in the upright position. 3. […]

• No harm, potential for more than minimal, patternF700Aug 23, 2022

  Based on observation, interview and record review, facility staff failed to attempt alternative interventions prior to the use of bedrails for six residents (Resident #2, #4, #5, #6, #7 and #202). Additionally, staff failed to obtain resident and/or guardian consent for the use of the bedrails, and failed to update the residents care plans for bedrail use. The facility census was 7. 1. Review of the facility's General Patient Care Policy, dated 12/21/21, showed one bed rail may be used. Patients will be educated on the risk of entrapment and must sign a consent form to have the bed rail up. […]

• No harm, potential for minimal, widespreadF655Jan 18, 2024

  Based on observation, interview, and record review, facility staff failed to develop baseline care plans to provide effective and person-centered care for three admitted residents (Resident #257,#258, #259). The facility census was 5. 1. Review of the facility's Patient Plan of Care - Skilled Nursing Facility, revised 01/09/20, showed staff are directed as follows: -An interim care plan is developed immediately after admission by nursing, dietary, and other disciplines as required to cover immediate needs of the patient; -The plan of care will be printed and given to the patient within 48 hours of admission with a current copy of active medication orders. Assessment: -The initial assessment is done on the day of admission. […]