The Club at Lake Gibson

In the surveyor’s words

From the most serious findings on record at The Club at Lake Gibson, in the surveyor’s own words.

• Actual harm, isolatedF689May 8, 2026

  Based on record review, observations and interviews the facility failed to ensure adequate supervision and appropriate use of equipment to safely transfer one resident (#1) out of five residents reviewed for sit to stand transfers with the assistance of two staff members. Findings included:During an observation interview on 5/6/26 at 10:11 a.m., Resident #1 said Staff A, CNA, did not have assistance from another staff member when the injury occurred. She said Staff A, CNA, had difficulty maneuvering the sit to stand lift over the raised threshold ('hump') in the bathroom doorway and repeatedly repositioned the lift to move it over the threshold. […]

• Actual harm, isolatedF726May 8, 2026

  Based on record review, interviews, and policy review, the facility failed to ensure nursing staff were competent in using the sit to stand mechanical lift for one resident (#1) of five residents sampled.Findings Included:On 4/12/26 staff failed to review and follow Resident #1's care plans related to functional abilities and the resident slid from a [vendor 3000] sit to stand machine and sustained a fractured femur and dislocated shoulder.On 4/12/26 at approximately 8:00 p.m. Staff A, Certified Nursing Assistant (CNA) used the [vendor 3000] sit to stand mechanical lift to transfer Resident #1. […]

• Actual harm, isolatedF689Dec 2, 2022

  Based on observation, interview, and record review, it was determined the facility failed to 1.) ensure staff implemented training received related to usage of a transfer lift, which resulted in a fractured right arm for one (Resident #50) of seven residents reviewed for falls; and 2.) assess, document, and treat an staff/resident incident, which resulted in a right elbow skin injury for one (Resident #322) of thirteen residents reviewed for accidents. Findings included: 1. Record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)]. Review of nurses' notes, written on 11/22/2022 at 1527 (3:27 p.m.), revealed the resident had been sent to the hospital due to a right arm dislocation. […]

• No harm, potential for more than minimal, widespreadF761Jul 18, 2024

  Based on observation, interview, and record review the facility failed to ensure medication was stored appropriately in three out of three medication carts audited and on two out of two units related to unlocked treatment cart, medication on the floor, and medication unlocked on medication carts. Findings included: An observation was conducted on 7/17/24 at 9:50 a.m. of a treatment cart at the end of the 300-hall sitting outside of a resident room. The nurse was inside the room, behind the privacy curtain. The medication cart had 2 intravenous medications and 1 topical medication sitting in the attached plastic side compartment that has no lock. No other staff were in the hall. The nurse, Staff E, Licensed Practical Nurse (LPN) exited the resident room and was interviewed at that time. […]

• No harm, potential for more than minimal, patternF880Jan 30, 2025

  Based on observations, interviews, and record review, the facility failed to ensure an effective infection control and prevention program to prevent the spread of infection was implemented by 1.) failing to use appropriate personal protective equipment (PPE) while performing care for three residents (#113, #49, and #84) on Enhanced Barrier Precautions on three (Upper 300 Hall, Lower 400 Hall, and Upper 400 Hall) of four facility Halls and 2.) failing to follow professional standards of practice for storage of respiratory equipment for one resident (#269) of four residents observed on respiratory therapy. […]