Lotus Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 26, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate staff supervision and a safe environment to prevent a cognitively impaired, vulnerable resident from exiting the facility unsupervised for 1 of 5 residents reviewed for elopement, of a total sample of 8 residents, (#1). On 7/22/22 at approximately 3:30 PM to 3:45 PM, the facility failed to prevent a cognitively impaired resident from exiting the facility unsupervised. Resident #1 walked past the receptionist's desk and exited the facility's front doors when they opened automatically. He walked approximately 300 steps to the end of the driveway and then proceeded to walk across a 4 lane heavily trafficked divided highway. […]

• Immediate jeopardy, isolatedF726Sep 16, 2021

  Based on interview and record review the facility failed to ensure nursing staff had appropriate competencies and skill sets to prevent significant medication errors for 1 of 3 residents who received [MEDICATION(S)] patch, (#1). On [DATE] at 1:41 PM, and 1:42 PM, the resident received 100 micrograms (MCG) of [MEDICATION(S)] instead of 50 MCG, double the prescribed dose. On [DATE] at approximately 12:00 PM, the resident fell from his wheelchair, and sustained a head injury with a laceration to his forehead. The resident was unresponsive with fixed pupils. He was transferred to the Emergency Department (ED) where two patches of [MEDICATION(S)] were noted on his chest. […]

• Immediate jeopardy, isolatedF760Sep 16, 2021

  Based on interview and record review the facility failed to ensure a [MEDICATION(S)] patch was administered per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:41 PM, and 1:42 PM, the resident received 100 micrograms (MCG) of [MEDICATION(S)] instead of 50 MCG, double the prescribed dose. On [DATE] at approximately 12:00 PM, the resident fell from his wheelchair, and sustained a head injury with a laceration to his forehead. The resident was unresponsive with fixed pupils. He was transferred to the Emergency Department (ED) where two patches of [MEDICATION(S)] were noted on his chest. […]

• Actual harm, isolatedF684Mar 3, 2023

  Based on observation, interview, and record review, the facility's nursing staff failed to adhere to standards of professional practice to promote skin integrity, obtain and implement appropriate wound care orders, and apply treatments and dressings as ordered for 2 of 2 residents reviewed for non-pressure skin conditions, of a total sample of 66 residents, (#61 & #30). The facility's failure to implement adequate preventative interventions and follow policies and procedures for skin and wound care resulted in actual harm for resident #61, preventable injuries during activities of daily living (ADLs) care and development of a skin infection. Findings: 1. […]

• Actual harm, isolatedF660Oct 19, 2022

  Based on interview and record review, the facility failed to implement an effective discharge planning process for discharge to home with Home Health Care services as ordered by the physician for 2 of 3 discharged residents, (#4, #8). Failure to implement an effective discharge plan for Home Health Care (HHC) services resulted in resident #4 and #8 not receiving required therapy services, Home Health Aide (HHA) services and Durable Medical Equipment (DME) to facilitate a smooth and safe transition from the facility to home. As a result, residents #4 and #8 experienced difficulties with daily routine, mobility, and excessive hardship for family members caring for the residents. Findings: 1. […]