Scott Lake Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Scott Lake Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 1, 2025

  Based on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from neglect related to medications not being reconciled and accurately transcribed, not reporting abnormal lab values and abnormal blood pressures to a provider for one resident (#1) out of three residents reviewed. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 8/22/25. The findings of Immediate Jeopardy were determined to be removed on 10/1/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: An interview was conducted on 9/30/25 at 11:45 a.m. […]

• Immediate jeopardy, isolatedF726Oct 1, 2025

  Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure the nursing staff was competent to reconcile hospital discharge medication orders, blood glucose levels were monitored for a diabetic resident, or recognize and respond to elevated blood pressures and abnormal lab results for one resident (#1) out of three residents reviewed. This failure created a situation that resulted in a worsened condition to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 8/22/25. […]

• Immediate jeopardy, isolatedF760Oct 1, 2025

  Based on record review, interviews, hospital record review, facility documentation and policy review, the facility failed to ensure one resident (#1) of three reviewed for new admission orders was free from significant medication errors as evidenced by the resident not receiving the correct medications order upon admission. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy beginning on 8/22/25. The findings of Immediate Jeopardy were determined to be removed on 10/1/25 and the severity and scope was reduced to a D after verification of removal of immediacy of harm. Findings included: An interview was conducted on 9/30/25 at 11:45 a.m. […]

• Immediate jeopardy, isolatedF609May 19, 2023

  Based on interviews with the Nursing Home Administer, the Director of Nursing, Assistant Director of Nursing, Nursing staff, Certified Nursing Aides, the resident's family members, the attending physician, Medical Director, and consultant pharmacist, and review of the facility's policies and the resident's medical record, the facility failed to prevent and report neglect for one (Resident #3) of three sampled residents. The facility failed to prevent neglect and report neglect for Resident #3 who had dementia and cognitive communication deficits, had an order for Fentanyl (narcotic to treat severe pain) patch every 72 hours 12 mcg (micrograms)/hour, apply 1 patch transdermal one time a day every 3 days related to pain and remove per schedule as of 04/26/22. […]

• Immediate jeopardy, isolatedF689May 19, 2023

  Based on observations, review of medical records and facility polices, interviews with facility staff, and the Medical Doctor, the facility failed to provide supervision and services to prevent an unwitnessed exit from the facility for one (Resident # 2) of fifteen residents at high-risk for elopement. The facility failed to provide adequate supervision, to place an electronic monitoring device on a resident known to wander, and failed to provide appropriate safety measures for an exit door, resulting in the resident leaving the facility without staff intervention. Resident #2 was cognitively impaired, at risk for falls related to difficulty walking, and was known by the night shift staff to get up at night and walk around the facility. […]