Lake Mariam Health And Rehabilitation Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that the facility failed to refund personal funds owed to two discharged residents within the required timeframe. For one resident, the resident’s representative reported on 04/29/2026 that they had not received a refund. Record review showed this resident had been discharged to a hospital on 08/10/2025 and subsequently died on 09/01/2025. The resident’s financial transaction report, covering 05/01/2025 to 03/31/2026, showed a patient liability credit of $620.29, indicating a refund was due from monies paid. Despite this, the Nursing Home Administrator (NHA) confirmed that the refund had not been issued, and the resident was more than 30 days post-discharge. For a second resident, records showed admission on an unspecified date and death on 08/20/2026. The financial transaction report for 07/01/2025 to 03/31/2026 showed a patient liability credit of $804.81, also indicating a refund was due. During an interview on 04/29/2026, the Business Office Manager (BOM) stated that this resident had requested a refund, and that a request for $804.80 had been sent to the corporate accounts payable office on 03/30/2026, but the refund had not yet been sent. The BOM and NHA both confirmed that refunds for these two residents had not been issued and that both cases exceeded 30 days post-discharge. Review of the facility’s undated “Refund of Overpayments” policy showed that personnel are to promptly refund overpayments, that monies on deposit are to be refunded upon request or death, that overpayments should be refunded as soon as possible but not later than 60 days (30 days if an electronic adjustment is possible), and that personal funds are to be made available to a deceased resident’s representative within thirty days of death.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves failures to report abnormal diagnostic results, complete ordered STAT labs, assess and document changes in condition, and timely administer ordered antibiotics for two residents with respiratory symptoms and complex medical histories. For one resident with dementia, hypertension, and anxiety, a CNA observed during an overnight shift that the resident was "not herself" and later found her sitting on the side of the bed gasping for air. The CNA reported this to an LPN, who attributed it to hiccups, attempted to obtain vital signs but could not get a pulse or O2 saturation due to cold hands, and then only "kept an eye" on the resident. There was no documented assessment, change in condition note, or provider notification related to this breathing concern. Later that day, another LPN documented that the resident had shortness of breath, slightly labored breathing, and an O2 saturation of 73% on room air, and obtained orders for O2 at 2 L, STAT CBC, STAT CMP, STAT chest x‑ray, nebulizer treatments, and UA/CS. For this same resident, the ARNP ordered STAT labs and a STAT chest x‑ray for shortness of breath, but the laboratory company reported there was no requisition or ticket for STAT labs and confirmed that no labs were drawn that day. The facility’s process required nurses to enter STAT orders into the lab website and mark them as STAT to trigger timely collection, which did not occur. A chest x‑ray was completed and reported to the facility, showing cardiomegaly, suggestion of mild pulmonary venous hypertension, and interval worsening of pulmonary congestion. There was no documentation that any provider was notified of these abnormal x‑ray results. That night, the CNA again found the resident unresponsive but breathing, without oxygen in place and with the concentrator unplugged. The LPN on duty documented that on arrival the resident was pale with gasping breaths, BP 96/60, pulse 58, RR 4–6, and O2 saturation 73% on 2 L O2, followed by cessation of respirations and loss of pulse, initiation of CPR, and transfer to the hospital. The PCP, partner physician, and ARNP all stated they had not been notified of the chest x‑ray results and would have given treatment orders if they had been informed. A second resident with dementia, aphasia, hemiplegia, and multiple comorbidities developed a cold, fever, and increasing respiratory symptoms over several days. A CNA reported that the resident was on oxygen and febrile over a weekend and appeared worse by Monday morning, when the resident’s representative found him lethargic, clammy, mottled, and gasping for air and requested immediate transfer to the hospital. On the prior Saturday, an LPN contacted the PCP when the resident’s temperature was 102°F, O2 saturation 89%, and lung sounds had crackles; the PCP ordered O2, nebulizer treatments, Ceftriaxone IM daily for three days, STAT chest x‑ray, STAT CMP, and STAT CBC. The weekend supervisor LPN entered orders for chest x‑ray, labs, Ceftriaxone, nebulizers, and O2, but the CBC and CMP were entered as routine labs for a later date rather than STAT, and there were no flu or COVID swab orders that day. The lab company later confirmed that STAT labs require a specific STAT ticket entry, and the DON confirmed that routine labs are not drawn on Sunday, delaying lab completion until Monday. For this second resident, the MAR showed that Ceftriaxone was not administered on the day it was ordered and was first entered to start the following day, when it was documented as refused, with no documentation that the provider or resident representative was notified of the refusal. The pharmacy confirmed that three doses of Ceftriaxone were delivered early the next morning and that no doses were pulled from the electronic medication dispensing machine on the day of the order or the following day. An LPN working the Sunday night shift stated she noticed the antibiotic had not been given and administered a dose between 1:00–2:00 a.m. Monday but did not document it. Progress notes documented fever, shortness of breath with labored breathing, abnormal vital signs, and new irregular pulse, with orders for additional labs, viral testing, repeat chest x‑ray, and PRN medications. Labs drawn Monday morning showed critically high sodium, elevated BUN and creatinine, hyperglycemia, and positive influenza A. The PCP later stated he expected labs to be completed as ordered and to be notified of results, and that if he had seen the critically high sodium on Saturday he would have ordered fluids. The surveyors determined that these failures resulted in a worsened condition and the likelihood for serious injury and/or death and cited Immediate Jeopardy, later reduced after verification of removal of Immediate Jeopardy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to properly enter and process STAT and routine laboratory orders in the electronic medical record and the external lab portal, resulting in ordered labs not being drawn or not being treated as STAT for multiple residents. For one resident with dementia and hypertension, an ARNP ordered STAT CBC, CMP, chest x‑ray, and other diagnostics after the resident was noted with shortness of breath, labored breathing, and an oxygen saturation of 73% on room air. The LPN caring for the resident stated that the unit manager entered the labs into the lab website, but the lab company reported there was no phone call or requisition ticket for STAT labs and confirmed that no labs were drawn that day. Later that night, another LPN found the resident pale, gasping, with very low respirations and oxygen saturation despite oxygen, and a code blue was initiated with CPR and EMS transfer to the hospital. The PCP and ARNP both stated they were not aware the STAT labs had not been completed and expected the orders to be carried out and results communicated. Another resident with aphasia, hemiplegia, dementia, and a determination of incapacity had orders for CBC and CMP and, per staff and PCP interviews, was to have STAT labs, STAT chest x‑ray, flu and COVID swabs, nebulizer treatments, oxygen, and Ceftriaxone after presenting with fever over 102°F, oxygen saturation of 89%, labored breathing, and crackles in the lungs. The LPN who contacted the PCP reported that all labs and the chest x‑ray were ordered STAT, but the weekend supervisor entered the CBC and CMP as routine labs scheduled for a later date, and flu/COVID tests were not ordered until two days later. The medical record lacked documentation of the change in condition and the STAT nature of the orders on the day they were given. The resident’s labs were ultimately collected later, showing critically high sodium and other abnormal values, and the resident was later sent to the hospital with altered mental status, hypoxia, high fever, and was diagnosed with influenza A, septic shock, and multiorgan failure. A third resident, cognitively intact with diabetes, obesity, hypotension, and a gastrostomy, experienced vomiting, poor intake, and increased confusion. The provider ordered STAT CBC, CMP, and ammonia level for nausea, vomiting, and confusion. One LPN entered the STAT lab orders into the facility charting system while another LPN believed the first nurse would enter the orders into the lab system. The lab later reported that the orders were entered as routine, not STAT, and that while CBC and CMP were drawn and resulted, the ammonia level was not completed due to a specimen issue and was only noted in the portal. A fourth resident with atherosclerotic heart disease, Lewy body neurocognitive disorder, hypertension, and cardiomegaly had an episode of vomiting and chest pain with elevated blood pressure; the NP ordered IM medications, nitroglycerin, and STAT chest x‑ray, CBC, and CMP. The chest x‑ray was completed the same evening, but the CBC and CMP were entered as routine and not drawn until the next morning, with the lab confirming they were not processed as STAT. The DON and PCP acknowledged that the timing between ordering and completion was not acceptable for STAT labs and that there were problems with the lab process and nursing follow‑through on STAT orders.

Removal Plan

• The Director of Nursing was educated by the Regional Nurse Consultant on the process to review clinical records to validate diagnostic testing was completed per provider orders and that providers were notified of results.
• The Director of Nursing reviewed clinical records of current residents with diagnostic test orders from the prior 30 days to validate labs/diagnostic tests were completed as ordered and notified providers of any discrepancies.
• The Assistant Director of Nursing/Staff Development Coordinator began educating licensed nurses on the process to obtain STAT labs from the current lab service.
• The ADON/SDC educated licensed nurses on the process to obtain STAT labs from the current lab service.
• The Staff Development Coordinator began competency validation for licensed nurses on the process for obtaining routine and STAT labs.
• Step-by-step instructions for obtaining labs through the lab website (including STATs) were placed in the front of each lab binder.
• Licensed nurse education on the lab process, provider notification, and documentation was completed for nurses (with sign-in sheets and voice/text education reports used to validate completion).
• An ad hoc QAPI was completed with the Medical Director, Administrator, Director of Nursing, and additional IDT members addressing adherence to policy/process for change in condition, following provider orders, obtaining STAT labs, reviewing diagnostic results, and notifying providers; discussion included provider access to the EMR and ability to view lab/diagnostic results.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a failure to safeguard resident-identifiable information and maintain confidential medical records when staff and the Medical Director used unsecured personal cell phones and standard SMS text messaging to communicate resident information. During an observation and interview with the Medical Director, text messages on his personal phone were observed containing a resident’s identifying information, including a photo and video of the resident. The Medical Director stated that staff regularly sent him text messages about residents. The facility’s policies required safeguarding clinical record information against unauthorized use and ensuring residents’ rights to personal privacy and confidentiality of their personal and medical records. Further interviews with nursing staff revealed that multiple nurses routinely used their personal phones and regular, non-secure text messaging to communicate protected health information to physicians. One LPN demonstrated how she used her personal phone to text the Medical Director about a resident’s health status and orders, and stated that staff took pictures of prescriptions and texted them to obtain orders. Another LPN and an RN each reported using their personal phones to call and text physicians, including sending pictures of lab results and prescriptions, and confirmed they did not use any special secure messaging system. In contrast, another LPN in training stated she would use the nurses’ station phone and fax machine and would not use her personal phone for such communications. The DON confirmed that staff were expected to use the nurses’ station phone to communicate with physicians and should not have used personal devices or texting for resident information, indicating that the observed practices were inconsistent with facility policy and resident privacy rights.

Penalty

Inspection fine: $12,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe and orderly discharge for a resident who was transferred to an inappropriate location following an altercation with another resident. The resident, who had a history of dementia and was deemed incapacitated, was arrested by the local police after pushing another resident. The arrest occurred despite the resident being housed in a memory care unit and having a documented history of behavioral issues. The facility did not document any discharge planning or alternative placement for the resident, and the resident's care plan was not updated to reflect any changes in discharge planning. The incident began when the resident was involved in a physical altercation with another resident, leading to police involvement. The police were informed by the facility staff that the resident was not incapacitated, which contradicted the resident's medical records. The resident was subsequently arrested and charged with battery. The facility's social services director and director of nursing confirmed that there were no progress notes related to discharge planning or finding alternative placement for the resident, and the resident's discharge care plan had not changed during their stay. The resident's power of attorney reported that the facility did not notify them of the arrest until after the resident was already in police custody. The facility later informed the power of attorney that the resident could not return to the facility, forcing them to sign discharge papers. The resident remained in jail for over a month before being transferred to an assisted living facility, which was deemed inappropriate by the power of attorney. The facility's failure to document the reasons for not readmitting the resident and the lack of a safe discharge plan contributed to the deficiency.

Penalty

Inspection fine: $12,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions and maintenance issues. During a tour of the facility, surveyors found that numerous resident rooms and common areas had air conditioning units with filters heavily caked with dust and debris. Additionally, several rooms had waterlogged and damaged baseboards, cracked and missing floor tiles, and rusted bathroom equipment, all of which compromised the cleanliness and safety of the environment. The presence of black biogrowth, suspected to be mold, was noted in various locations, including behind doors, on walls, and on ceiling tiles in resident rooms and common areas such as dining rooms and hallways. Despite these observations, the Maintenance Director denied the presence of mold and stated that any suspected mold-like biogrowth was cleaned with detergent and a mold-killing paint product. However, there was no documentation to support the cleaning or maintenance of these areas, and the Maintenance Director admitted to being the sole maintenance staff, which led to delays in addressing these issues. Interviews with housekeeping staff revealed a lack of training and procedures for dealing with mold-like substances, and they reported these issues to the maintenance department. The interim Housekeeping Director, who had just assumed the role, was unaware of the location of cleaning schedules and procedures. The Nursing Home Administrator was also unaware of any mold-like substances in the building and could not provide documentation of the process for handling such issues. The facility's policy emphasized providing a safe and clean environment, but the lack of effective communication and documentation between departments contributed to the deficiencies observed.

Penalty

Inspection fine: $12,529

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a copy of the transfer and discharge notice to the Office of the State Long-Term Care Ombudsman for a resident who was reviewed for transfer and discharge rights. The resident was originally admitted to the facility with diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder, and generalized anxiety disorder. The Nursing Home Transfer and Discharge Notice for the resident indicated that the notice was given, but it lacked details such as the address and phone number of the transfer location, which was the county jail. Additionally, the section indicating that the notice was given to the Local Long Term Care Ombudsman Council was left incomplete. An interview with the Social Services Director (SSD) revealed that the discharge process typically included a documented discharge note, a discharge summary, and notification to the Ombudsman. However, the SSD admitted that the Ombudsman was only notified of hospital transfer discharges and planned discharges, not unplanned ones like the resident's transfer to jail. The SSD also mentioned that there were no transcripts confirming the receipt of faxes for the last three months, and the facility's IT department deleted emails after 30 days, leaving no confirmation of the paperwork being faxed. The facility's discharge planning policy did not specify expectations regarding Ombudsman notifications for transfers and discharges.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from sexual abuse by another resident, leading to multiple incidents involving residents with severe cognitive impairments. Resident #1, who had a documented history of inappropriate sexual behavior, was involved in several incidents with other residents. Despite being aware of Resident #1's behavior, the facility did not implement effective interventions to prevent further abuse. On multiple occasions, Resident #1 was observed engaging in sexual acts with other residents who lacked the capacity to consent, including incidents on 9/5/23, 3/29/24, 4/15/24, and 4/16/24. Resident #2, who was severely cognitively impaired and receiving hospice care, was involved in two incidents with Resident #1. On 4/15/24, Resident #2 was observed watching Resident #1 masturbate, and on 4/16/24, Resident #2 was found in a compromising position with Resident #1. Despite these incidents, staff did not respond adequately to protect Resident #2 from further abuse. Resident #2's care plan indicated severe cognitive impairment and a lack of capacity to consent, highlighting the vulnerability of the resident. Resident #4 and Resident #8 also experienced inappropriate sexual contact with Resident #1. Resident #4, who had severe cognitive impairment and was receiving hospice care, was found naked with Resident #1 in September 2023. Resident #8, also severely cognitively impaired, was involved in an incident on 3/29/24 where another resident was observed touching them inappropriately. The facility's failure to implement effective interventions and monitoring allowed these incidents to occur, resulting in a determination of Immediate Jeopardy.