Lake Ridge Center

In the surveyor’s words

From the most serious findings on record at Lake Ridge Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Dec 21, 2021

  Based on observation, interview, and record review, the facility failed to assess, monitor, and appropriately treat the worsening of pressure injuries, in accordance with professional standards, resulting in a stage IV pressure injury, for 1 of 1 Resident (49) who admitted to the facility with two Stage II pressure injuries, one on the coccyx (tailbone - a bone structure at the base of the spine) and one on the lower back/spine. Additionally, the facility failed to conduct appropriate monitoring and assessment for 3 of 3 residents (9, 29 and 17) in accordance with professional standards for wound treatment. […]

• Actual harm, isolatedF690Oct 16, 2025

  Based on interview and record review, the facility failed to ensure orders given by a urologist [a doctor who specializes in the urinary system (the body's drainage system for filtering waste and excess fluid to produce and expel urine) and male reproductive system] were completed and reviewed, in a manner that met professional standards of practice, for 1 of 3 residents (Resident 1) reviewed for change in condition related to the urinary system. Resident 1 experienced harm when they were hospitalized for sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection causing widespread inflammation and injury to organs) related to an untreated urinary tract infection [(UTI) an infection in any part of the urinary system--the kidneys, ureters,… […]

• Actual harm, isolatedF684May 9, 2025

  Based on observation, interview, and record review the facility failed to 1) thoroughly evaluate and monitor the significant changes in a resident's respiratory condition and increased sedation from medications given for 1 of 3 residents (Resident 1) reviewed for change of condition; 2) accurately assess and notify the provider timely of wound changes for prompt medical evaluation for 1 of 3 residents (Resident 11) reviewed for skin conditions; 3) follow through with specialized services for 2 of 2 residents (Resident 34 and 57) reviewed for quality of care. This failed practice placed residents at risk of not receiving the care and services they needed to prevent a decline in their health and/or mobility. […]

• Actual harm, isolatedF689May 9, 2025

  Based on interview and record review, the facility failed to ensure the supervised fall risk residents received adequate supervision of one staff assistance in the dining room, and proper use of fall prevention devices for 1 of 5 residents (Resident 218) reviewed for falls. Resident 218 experienced harm when they fell forward out of their wheelchair when staff forgot to place the drop-down seat into the reclining position after transferring the resident to their wheelchair and sustained an injury to their left forehead that required hospital intervention for control of bleeding and stitches. Findings included . […]

• Actual harm, isolatedF692May 9, 2025

  Based on observation, interview and record review, the facility failed to ensure residents at risk for weight loss were reviewed for of 1 of 5 sampled residents (Resident 1) reviewed for nutrition. Resident 1 experienced harm as they had a 18.67% significant, unplanned, weight loss from 03/13/2025 to 04/22/2025 (40 days) and was found to have low protein levels and skin issues. This placed residents at risk for unplanned weight changes, health complications and nutritional decline. Findings included . <Nutritional Assessments> Review of the facility's 05/01/2023 Food and Nutrition Services Policies and Procedures showed that residents were assessed on admission and routinely thereafter. […]