Lila Doyle Post Acute

In the surveyor’s words

From the most serious findings on record at Lila Doyle Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 5, 2023

  Based on interviews, record review, document review, and policy review, the facility failed to ensure 1 (Resident (R)2) of 2 sampled residents reviewed for abuse was not sexually abused by a visitor of the facility. On 10/30/2023, a certified nursing assistant (CNA) witnessed a visitor fondle (stroke or caress lovingly, or erotically) the breast of a cognitively impaired resident, R2. Instead of immediately intervening to separate the resident from the visitor, the CNA left the resident alone in their room to report the incident to a nurse, Licensed Practical Nurse (LPN)6. LPN6 then removed the resident from their room but did not escort the visitor out of the facility, as listed in the facility's abuse policy. […]

• Actual harm, isolatedF689Feb 4, 2026

  Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to assess a resident to determine the level of supervision required while outside and ensure the environment was safe. On 11/22/2025, Resident (R)4, a resident with severe cognitive impairment, was taken outside by a staff member and left without direct supervision of staff. The staff failed to ensure the gate that enclosed the area was secured and the resident's wheelchair brakes were locked. R4 rolled down a hill, fell out of their wheelchair, and sustained an impacted left femoral neck fracture. The facility failed to ensure fall risk interventions were implemented for R2 and R8. […]

• No harm, potential for more than minimal, isolatedF610Nov 5, 2023

  Based on interviews, record review, document review, and policy review, the facility failed to conduct a thorough investigation following an allegation of sexual abuse for 1 resident (Resident #2) of 2 sampled residents reviewed for abuse. Findings included: Review of a facility policy titled, Abuse: Prevention of and Prohibition Against, revised in October 2022, revealed, 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. The policy specified, 5. […]

• No harm, potential for more than minimal, isolatedF550Jul 13, 2023

  Based on observations, interviews, record review, and review of the facility's policy, the facility failed to promote the dignity of 1 (Resident (R) 6) of 1 resident who was observed with staff standing while assisting the resident to eat. Findings include: Review of the facility's policy titled, Resident Rights: Respect and Dignity, dated 10/04/16, revealed . You have the right to be treated with respect and dignity . reside and receive services in the facility reasonable accommodation of your needs and preferences . […]

• No harm, potential for more than minimal, isolatedF656Jul 13, 2023

  Based on observation, interview and record review, the facility failed to implement the care plan for 1 (Resident (R)43) of 1 resident reviewed for skin conditions. Specifically, the failure to apply the skin protection devices placed R43 at risk for additional skin tears. Findings include: Review of R43's Medical Diagnosis, located in R43's electronic medical record (EMR) found in the Medical Diagnosis tab, revealed R43 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; diabetes, heart failure, and pressure ulcer. Review of a Nursing Note dated 05/01/23 at 5:08 AM and located in the Progress Notes tab of R43's EMR, noted, . […]