Lakefront Nursing & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Lakefront Nursing & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 7, 2021

  Based upon observation, interview and record review the facility failed to ensure that one of six residents (R2) in the sample remains free from abuse/neglect, failed to implement the abuse/neglect policy, and failed to ensure that professional boundaries between staff and residents are not crossed. On 5/10/21, R2 eloped from the facility (approximately 15 hours) with V3 (LPN/Licensed Practical Nurse) while off-duty (unbeknownst to staff). R2 refused to return to the facility therefore was carried by his arms and legs while suspended in the air from [NAME] Street back to the facility (approximately 100 yards) by V1 (Administrator/Abuse Coordinator), V7 (Security Guard), and V14 (CNA/Certified Nursing Assistant). […]

• Immediate jeopardy, isolatedF689Jun 7, 2021

  Based upon observation, interview and record review the facility failed to conduct bed checks (every 2 hours), failed to provide supervision to one of six residents (R2) in the sample, and failed to implement the elopement policy. On 5/10/21 at 1:02am, R2 exited the facility with V3 (LPN/Licensed Practical Nurse) while off-duty (unbeknownst to staff), a code yellow was called at approximately 7am (6 hours later). R2 did not return to the facility until 4:28pm (approximately 15 hours after leaving the facility). On 5/17/21 at 1:31pm, R2 affirmed he sustained injuries (5/10/21) to his arms, legs and left shoulder. R2's (5/14/21) hospital records state he may have been in a fight resulting in injuries to left wrist/shoulder, right wrist and both feet. […]

• Actual harm, isolatedF600Sep 22, 2023

  Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for one (R4) out of three residents reviewed for abuse. This incident resulted in one (R4) resident feeling emotionally and psychologically traumatized. Findings include: R4 is a [AGE] year-old female with a BIMS (Brief Interview for Mental Status) score (4/20/2023) of 15, which means R4's cognition is intact. Per Face sheet, R4 has diagnosis of major depression. R4's abuse care plan documents: History of sexual abuse. On 09/19/2023 at 11:32 AM, R4 was inside her room, alert and able to express her thoughts very well. […]

• Actual harm, isolatedF684May 11, 2023

  Based on observation, interview, and record review the facility failed to provide a working wound vacuum and failed to assess one resident's (R85) wound. These failures affected one resident (R85) causing (R85's) wound to have a foul odor, purulent greenish drainage and (R85) feeling embarrassed due to the odor that permeated (R85's) room. Findings include: R85's Face sheet documents R85 has a diagnosis that include but not limited to acute hematogenous osteomyelitis left ankle and foot, unspecified abnormalities of gait and mobility, other lack of coordination, peripheral vascular disease, idiopathic aseptic necrosis of the femur, complete traumatic amputation at level between knee and ankle unspecified lower leg sequela and acquired absence of unspecified foot. […]

• Actual harm, isolatedF697May 11, 2023

  Based on observation, interview, and record review the facility failed to assess and rate pain for one resident (R73) that was experiencing a tooth ache and failed to administer pain medication as ordered. This failure resulted in R73 experiencing severe pain with facial grimacing and pain with eating. Findings Include: R73's admission record includes but not limited to diagnoses of schizoaffective disorder, atherosclerotic heart disease, chronic obstructive pulmonary disease, encephalopathy, hypertension, anxiety, and paranoid schizophrenia. R73's (2/21/23) Brief Interview of Mental Status documents a score of 15. (Cognitively intact). On 5/8/23 at 10:55 am surveyor observed R73 lying in bed with the covers pulled over R73's head. […]