The Lakes

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 11, 2024

  On 10/09/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide adequate supervision to prevent elopement for Resident #1 with severe cognitive impairment, daily wandering behaviors, and a history of elopement. An initial State Reportable Incident, dated 10/06/24, documented the facility charge nurse was called and notified by the local church Resident #1 was at their facility. It documented the resident was assessed and noted to have bruising to left and right lower extremities, and bilateral knees. It documented the resident reported they fell but did not hit their head. It documented the resident was sent to the ER and would be placed on 1:1 with staff to ensure safety. […]

• Actual harm, isolatedF689Dec 18, 2024

  Based on observation, record review, and interview, the facility failed to prevent a resident from a fall resulting in a close head injury during the provision of care for one (#3) of three sampled residents reviewed for accidents. The administrator identified 67 residents resided in the facility and 34 residents required assistance with activities of daily living. Findings: The Safety and Supervision of Residents policy, revised 07/2017, read in part, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Resident #3 had diagnoses which included vascular dementia and Alzheimer's disease. Resident #3's care plan for ADLs and falls, revised 10/29/24, documented the resident: a. was dependent on staff for bed mobility, b. […]

• No harm, potential for more than minimal, patternF644Nov 21, 2024

  Based on record review and interview, the facility failed to ensure a resident with a new diagnosis of a serious mental health condition had a pre-admission screening and resident review updated for one (#1) of one sampled resident reviewed for PASARR level two. The DON identified 28 residents with serious mental health diagnoses. Findings: The facility policy titled, Admission Criteria, read in part, Nursing and medical needs of individuals with mental disorders, intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission and Resident Review program (PASARR) to the extent possible. Resident # 1 had diagnoses which included psychosis, anxiety, and recurrent depression. […]

• No harm, potential for more than minimal, patternF656Nov 21, 2024

  Based on record review and interview, the facility failed to develop a comprehensive care plan for: a. IV and antibiotic usage for one (#20); b. visual function for one (#6); and c. antipsychotic medication use for one (#35) of 18 sampled residents whose care plans were reviewed. The DON identified 71 residents who resided in the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, revised 12/16, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. […]

• No harm, potential for more than minimal, patternF686Nov 21, 2024

  Based on observation, record review and interview, the facility failed to ensure wound treatments were provided for one (#18) of two sampled residents reviewed for pressure ulcers. The DON identified three residents had been admitted to the facility with wounds since 10/01/24. Findings: An undated facility policy, Guidelines for Notifying Physician of Clinical Problems, read in part, These guidelines are to help ensure that .medical problems are communicated to the medical staff in a timely efficient manner .The charger nurse or supervisor should contact the attending physician at anytime if they feel a clinical situation requires immediate discussion and management .the nurse should have the the following information available .active medical problems. […]