Lakeland Hills Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Apr 11, 2025

  Based on record review and interviews, the facility failed to protect the residents' right to be free from neglect for four residents (#4, #5, #3, and #2) out of six residents sampled related to 1) failure to accurately reconcile medications, 2) failure to follow-up on physician orders for laboratory testing, medical equipment, and outpatient services, 3) failure to provide medication with a physician's order, 4) failure to follow a physician's order for blood sugar testing, and 5) failure to implement hospice consultation orders. Serious harm occurred on [DATE], when Resident #4's seizure medications were not reconciled accurately, resulting in Resident #4 experiencing two seizures. […]

• Immediate jeopardy, patternF726Apr 11, 2025

  Based on record review and interviews, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for six residents (#4, #5, #1, #3, #6, and #2) out of ten residents sampled related to 1) failure to accurately reconcile medications upon admission, 2) failure to follow-up on laboratory orders, 3) failure to provide medication only with a physician's order, 4) failure to report and document malfunctions with a gastrostomy tube (G-tube), 5) failure to practice within the nursing scope of responsibility, 5) failure to follow a physician's order related to blood sugar testing, and 6) failure to implement hospice consultation orders. […]

• Immediate jeopardy, patternF760Apr 11, 2025

  Based on record review and interviews, the facility failed to ensure three residents (#4, #5, and #3) out of six residents sampled for medication administration were free from a significant medication error as evidenced by 1) failure to accurately reconcile medications upon admission, and 2) failure to provide physician ordered medications. Serious harm occurred on [DATE], when Resident #4's seizure medications were not reconciled accurately, resulting in Resident #4 experiencing two seizures. After the seizures, physician ordered laboratory tests for seizure medication levels were not implemented, and Resident #4 had a third seizure resulting in a fall with head trauma and transfer to a higher level of care. […]

• No harm, potential for more than minimal, widespreadF812Aug 12, 2024

  Based on observation, interview, and record review, the facility did not ensure food was stored, prepared, and handled safely in accordance with professional standards for food service safety. The facility failed to ensure food and beverages were labeled, dietary staff members donned gloves as necessary, cleanliness of a drying rack, cookware was sanitized and clean, plates were not chipped, and the thermometer was calibrated appropriately in one of one kitchen. Findings included: On 8/12/24 at 9:30 a.m., a tour of the kitchen with the Certified Dietary Manager (CDM) and the Senior Registered Dietitian (Sr RD) revealed three clear containers of red juice in the walk-in cooler. An observation of the three containers of red juice revealed no date on them. […]

• No harm, potential for more than minimal, widespreadF880Sep 28, 2023

  Based on observations, interviews, and record review the facility failed to implement an effective infection control program as evidence by 1) failure to handle, store, process, and transport all linens and laundry in accordance with appropriate infection control practices to produce hygienically clean laundry for 104 out of 104 residents, and 2) failure to ensure appropriate hand hygiene was completed after delivering a meal tray to one isolation room (room [ROOM NUMBER]) of one isolation rooms, and 5 rooms (room [ROOM NUMBER], 308, 310, 311 and 313)out of 15 rooms observed for meal service. Findings included: On 9/28/2023 at 8:03 AM an observation occurred in the central laundry room, of two washing machines. […]