Lighthouse Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Lighthouse Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 20, 2026

  Based on observations, interviews and record review, the facility failed to ensure the Resident's environment was free from accident hazards, for one Resident #126, out of a sample of 30 Residents. Specifically, the facility failed to implement a fall care plan intervention which led to Resident #126 falling and sustaining a fracture.Findings include:A review of the facility policy titled 'Falls-Clinical Protocol' with a revision date of September 2012 indicated the following:-The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. […]

• Actual harm, isolatedF692May 13, 2021

  Based on observation, record review, and interview, the facility failed to identify and address significant weight losses for 3 Residents (#55, #73, and #70) out of a total of 24 sampled residents. Findings include: Review of the facility policy titled Weights and Heights, dated 1/31/20, indicated the following: -Policy: Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary team. -Purpose: To obtain baseline weight and identify significant weight change, to determine possible causes of significant weight change. -Significant Weight Change Management: Significant changes will be reviewed by the licensed nurse for assessment. […]

• No harm, potential for more than minimal, widespreadF851Feb 14, 2025

  Based on record review and interview, the facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 4 2024 (July 1 - September 30), in accordance with the schedule specified by CMS. Findings include: During an interview on 2/11/25 at 2:58 P.M., with the facility Administrator he said that he started at the facility in November 2024 and was aware that the facility had not submitted the previous quarters staffing data to CMS. The Administrator said that at that time the facility was owned by another company. […]

• No harm, potential for more than minimal, patternF609Feb 14, 2025

  Based on record review and interviews, the facility failed to report allegations of potential abuse (injuries of unknown, and an allegation of neglect) to the State Agency for three Residents (#87, #118, and #55) out of a sample of 30 Residents. 1. For Resident #87, the facility failed to report an X-ray (X-radiation-images created inside of a body by passing beams of radiation through the body) positive for a fracture from an unknown origin to the State Agency within two hours. 2. For Resident #118 the facility failed to notify the state agency of an injury of unknown within 2 hours once the Director of Nursing became of a new fracture (an acute right intertrochanteric [thigh bone] fracture) of unknown origin. 3. […]

• No harm, potential for more than minimal, patternF759Feb 14, 2025

  Based on observations, interviews, and record reviews for three Residents (#22, #376 and #70) out of four residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. Three out of four nurses observed made 3 errors out of 33 opportunities resulting in a medication error rate of 9.09%. Specifically, 1.) For Resident #22, Nurse #1 administered the incorrect dose of a medication spray (Fluticasone, medication used for allergies) 2.) For Resident #376, Nurse #4 did not follow manufacture's recommendations and crushed a medication (metoprolol extended-release tablet, cardiac medication that once crushed becomes immediate release) which indicated do not crush. […]