Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Placid Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, mood disorder, depression, and anxiety, and with severe cognitive impairment, was started on and had dose changes to psychotropic medications (Haldol and Depakote) without prior notification to or consent from the Health Care Surrogate (HCS). The HCS reported not being informed before these medications were implemented and was upset about the lack of communication. An LPN and the unit manager described a facility process requiring prior HCS notification, risk discussion, and a signed psychotropic consent form, but acknowledged that the resident received multiple doses of Depakote and a Haldol injection before any psychotropic consent form was signed. MAR and progress notes confirmed administration of these medications and later documentation of consent, while the DON confirmed that consent should have been obtained and that there was no documentation showing the family was notified before the psychotropic medications were initiated.
A resident with multiple chronic conditions experienced a decline in appetite, responsiveness, and continence over several days, which was observed and reported by a CNA but not promptly assessed by nursing staff. Despite family concerns and requests for evaluation, no timely assessment or vital signs were documented by LPNs or the DON. The resident was eventually sent to the hospital and admitted for sepsis and dehydration, with facility records showing gaps in monitoring, documentation, and adherence to care plan interventions.
Multiple residents did not receive meals that accommodated their documented allergies, intolerances, and dietary preferences. One resident with a vegetarian diet repeatedly received meat, resulting in emotional harm and discharge against medical advice. Another resident with a shellfish allergy was served shrimp, and two others did not receive correct meal portions or were served foods they could not tolerate. These failures were confirmed through observations, interviews, and record reviews, showing a breakdown in the facility's dietary service processes.
The facility did not ensure accurate and complete PASARR Level I and II screenings for multiple residents with diagnoses of serious mental illness or intellectual disability. Several residents were admitted with psychiatric and behavioral health conditions, but their PASARR documentation was incomplete, missing, or not updated to reflect their diagnoses, and required Level II evaluations were not conducted. The process for managing PASARRs was inconsistent, with gaps in staff access and oversight, resulting in noncompliance with regulatory requirements.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Staff failed to consistently perform hand hygiene between tasks such as passing meal trays, assisting residents, and handling garbage, and did not offer or assist residents with hand hygiene prior to meals. Several staff members had fingernails and hair styles not in compliance with facility policy and CDC guidelines, and one CNA used a personal cloth to wipe perspiration while continuing to assist with meal service without hand hygiene. Residents with moderate cognitive impairment were not offered hand hygiene before meals, and staff did not always follow hand hygiene protocols during medication administration and meal service.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
The facility did not consistently log or address grievances raised by residents and their representatives, including concerns about staff behavior, call light response times, and dietary services. Despite staff awareness of the grievance process, concerns were not documented or followed up on, and residents did not receive communication regarding the resolution of their issues, contrary to facility policy.
The facility did not ensure that two residents and their representatives received proper documentation and notification regarding transfer or discharge. For one resident with severe cognitive impairment and multiple mental health diagnoses, there was no record of notification or the required transfer/discharge notice when transferred to the hospital. For another resident with cardiac and vascular conditions, discharge documentation was incomplete and unsigned, and there was no evidence that the required notice or discharge information was provided.
Surveyors found multiple safety deficiencies, including an unsecured and hot steam table accessible to residents, restrooms without emergency call cords, and unlocked cabinets containing hazardous chemicals. Additionally, a resident with behavioral disturbances and a history of aggression was left unsupervised despite orders for 1:1 supervision. The DON and staff confirmed these lapses in safety and supervision.
Surveyors identified that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
Surveyors found that medication carts and storage areas contained expired, undated, and loose medications, including unlabeled vials and open bottles without dates. Controlled substances were not properly secured, with narcotic boxes attached to removable shelves and emergency kits not affixed. CPR carts containing glucose gel were left unlocked, and medications were observed unsecured on carts and at residents' bedsides, even though no residents were approved for self-administration. Staff interviews confirmed these lapses despite facility policies requiring secure and proper medication storage.
Incomplete discharge documentation and QAPI oversight failures were identified when the facility was recited for discharge process deficiencies. Three residents with intact or near-intact cognition had incomplete Nursing Home Transfer and Discharge Notice forms, with missing physician/designee signatures, resident or representative signatures, and required dates. The NHA acknowledged the forms should have been signed and dated before discharge, but the records reviewed were not complete.
Residents on one unit did not receive their meal trays at the same time, resulting in some watching others eat or waiting extended periods for their food. One resident consumed another's drink and ice cream while unsupervised, and another remained at the table with a dirty tray long after the meal. Staff interviews revealed a lack of training on serving meals together, and a nurse administered eye drops at the dining table, all of which failed to uphold resident dignity.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency in care planning and transition.
Three residents did not receive adequate assistance with ADLs, including grooming, nail care, haircuts, and shaving. One resident had matted hair and overgrown nails, another was unable to get a haircut due to the absence of a beautician, and a third had unaddressed facial hair and inconsistent shaving assistance. Staff interviews and documentation revealed lapses in providing and recording these essential care services, despite residents' dependence on staff and facility policy requirements.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility failed to follow its own policies for reporting irregularities found during the review.
A resident with moderate cognitive impairment and multiple diagnoses expressed a desire to transfer to another facility, but staff did not document her request or any follow-up discussions. The facility failed to honor and facilitate the resident's right to self-determination, as required by policy.
The facility failed to maintain a proper grievance process for three residents, with issues including missing documentation, unresolved grievances, and lack of follow-up. A resident's missing clothing was not properly documented, another resident's missing money was not deposited into their trust account, and a third resident's complaint about cold meals was not resolved. The Social Service Director admitted to not addressing grievances comprehensively in QAPI meetings.
A resident's personal funds were not returned within 30 days of discharge. The facility failed to document and resolve a grievance regarding missing money. The Business Office Manager confirmed that $11 remained in the safe, and $4 was given to the resident without proper documentation.
Failure to Obtain HCS Consent Prior to Psychotropic Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to inform and obtain consent from a resident’s Health Care Surrogate (HCS) prior to initiating and changing psychotropic medications. The resident, who had diagnoses including other specified mood disorders, unspecified dementia with behavioral disturbance, major depressive disorder, and anxiety disorders, was admitted in 2025 and had severe cognitive impairment as evidenced by a BIMS score of 3 on a later MDS. The HCS reported that the facility did not communicate medication changes before they were implemented, specifically noting the initiation of Haldol and Depakote after the resident exhibited behavioral issues. The HCS expressed being upset that these changes were not communicated in advance. Interviews with staff confirmed that facility practice and expectation were that the HCS should be notified and consent obtained before starting psychotropic medications. Staff A, an LPN, stated that the unit manager was supposed to notify the family before starting psych medications and that there was no reason not to notify the HCS prior to initiating such medications; Staff A also stated the HCS had refused psychotropic medication for the resident. Staff B, an LPN and Unit Manager, described the process for obtaining psychotropic consent, including calling the HCS, explaining risks, documenting verbal consent on a psychotropic medication form, and uploading the form and a progress note to the medical record. However, Staff B acknowledged that Haldol was ordered on 04/11/2025 and administered on 04/26/2025, and that Depakote had been administered and later dose-adjusted in April 2025, without a psychotropic consent form signed prior to those administrations. Record review corroborated that the resident received multiple psychotropic medications before documented consent was obtained. The MAR showed administration of divalproex sodium 125 mg from 04/01/2025 through 04/13/2025, Depakote ER 250 mg from mid- to late April 2025, Depakote ER 500 mg starting 04/28/2025, and a Haldol injection on 04/26/2025. A psychotropic medication administration disclosure/consent form was dated 04/28/2025, and Staff B stated this was the first psychotropic consent form seen for Depakote, acknowledging it should have been signed before the resident received Depakote and Haldol. Progress notes documented behavioral issues and the use of Haldol for severe agitation, as well as a late entry note on 04/28/2025 indicating that a behavioral health provider assessed the resident and that a family member gave consent for medication at that time. The DON confirmed that consent should have been obtained for Haldol and Depakote prior to administration, that families were typically contacted before psychotropic medications were given, and that there was no documentation in the record confirming that the provider had notified the family before the medications were started.
Failure to Timely Assess and Respond to Change in Condition
Penalty
Summary
The facility failed to identify and assess a change in condition in a timely manner for a resident with multiple complex diagnoses, including multiple sclerosis, adult failure to thrive, a history of urinary tract infections, cystic liver disease, dysphagia, and abnormal weight loss. The resident was noted by a CNA to have decreased appetite and changes in behavior over several days, including being less responsive and not exhibiting her usual complaints during care. Despite these observations, the CNA's concerns were not promptly acted upon by nursing staff, and no documented assessments or vital signs were recorded during the period when the resident's condition was changing. On the day of the incident, both the CNA and the LPN observed that the resident was more tired than usual and not at her baseline. The LPN attributed the resident's fatigue to possible poor sleep and did not perform an assessment or obtain vital signs. The unit manager and the DON were also made aware of the resident's change in condition, but again, no assessment or vital signs were documented. The family was notified and requested a urinalysis, which was ordered, but staff were unable to obtain a sample. Later in the day, the resident was found to be unresponsive and hot to the touch, at which point she was sent to the hospital and subsequently admitted for sepsis and dehydration. The facility's documentation revealed a lack of timely and thorough assessment following reports of a change in condition, as well as gaps in monitoring and documentation of the resident's nutritional status and weight trends. The care plan for the resident included interventions for monitoring for signs of malnutrition, dehydration, and infection, but these were not effectively implemented. Facility policies and job descriptions require prompt assessment and documentation of changes in condition, but these were not followed in this case, resulting in a failure to provide necessary care and monitoring.
Failure to Honor Dietary Allergies, Intolerances, and Preferences
Penalty
Summary
The facility failed to ensure that food allergies, intolerances, and dietary preferences were honored for four out of five residents reviewed for nutritional services. One resident, who was a vegetarian with a moderate cognitive impairment, repeatedly received meals containing meat despite clear documentation of her dietary restrictions and multiple grievances filed on her behalf. The resident and her family communicated these concerns to staff, and the care plan specifically noted her vegetarian status and food preferences. Despite these measures, the resident continued to receive incorrect meals, leading to emotional distress and ultimately her discharge against medical advice. The facility was unable to provide a vegetarian menu to surveyors upon request, and meal tickets did not consistently reflect the resident's preferences or the interventions taken by dietary staff. Another resident with a documented shellfish allergy was served shrimp, contrary to the dietary order and meal ticket instructions. Staff interviews revealed that the process for assembling meal trays involved multiple checks, but the system failed, resulting in the resident being exposed to an allergen. The resident had a history of moderate allergic reactions to shellfish, and the care plan included clear instructions to avoid exposure. Staff confirmed that the resident had previously experienced a reaction to shrimp, and the allergy was documented in the medical record. Despite this, the resident was served shrimp, and the incident was only discovered after the meal was delivered. Additional deficiencies included a resident who was supposed to receive large portions but consistently received standard portions, and another resident with lactose intolerance and diabetes who was repeatedly served dairy products and sweets. In both cases, the residents' dietary needs were clearly documented in their records and on meal tickets, but the kitchen staff failed to provide the correct meals. These failures were confirmed through direct observation, interviews with residents and staff, and review of dietary documentation.
Failure to Complete Accurate PASARR Screenings for Residents with Mental Illness or Intellectual Disability
Penalty
Summary
The facility failed to ensure that Level I and Level II Preadmission Screening and Resident Review (PASARR) screenings were accurate and complete for 12 out of 14 sampled residents. Multiple residents were admitted with diagnoses such as bipolar disorder, schizoaffective disorder, major depressive disorder, generalized anxiety disorder, and other serious mental illnesses, yet their PASARR Level I screens either did not reflect these diagnoses or failed to indicate the need for a Level II evaluation. In several cases, the PASARR forms were incomplete, blank, or missing critical information, and no Level II PASARR was conducted despite qualifying diagnoses and evidence of functional impairment due to mental illness. Interviews with the Director of Nursing (DON) revealed that the facility's process for handling PASARR screenings was inconsistent and lacked oversight. The DON confirmed that PASARRs were not always available upon admission and that the responsibility for completing and updating PASARRs was assigned to social services staff, who were not consistently present or available. The DON also acknowledged that she did not verify the accuracy or completion of PASARRs and that there was no current access to the PASARR system by facility staff, resulting in delays or omissions in required screenings and referrals for Level II evaluations. The medical records reviewed showed that residents with significant psychiatric and behavioral diagnoses were not properly identified in the PASARR process, and in some cases, residents were receiving psychotropic medications and behavioral interventions without the required PASARR documentation. Facility policy required prompt referral for Level II PASARR when a serious mental disorder or intellectual disability was identified, but this was not consistently followed. The lack of accurate and timely PASARR screenings led to residents with serious mental illness or intellectual disability not being properly evaluated as required by federal regulations.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Follow Infection Control and Hand Hygiene Practices During Meal and Medication Service
Penalty
Summary
Multiple observations and interviews revealed that staff did not consistently follow infection prevention and control practices during meal service and medication administration. Staff members, including CNAs, the Activities Director, and dietary staff, were observed failing to perform hand hygiene between tasks such as passing meal trays, assisting residents, handling garbage, and touching their faces. In several instances, staff did not offer or assist residents with hand hygiene prior to meals, despite residents expressing a desire for such assistance. Additionally, hand sanitizer dispensers were found to be empty or inaccessible to residents who required help. Further deficiencies were noted in personal hygiene practices among staff. Several staff members, including CNAs and nurses, were observed with fingernails extending beyond the facility's policy limits and CDC recommendations, and with hair styles that could interfere with care. One CNA was seen repeatedly using a personal cloth to wipe perspiration from their face and then continuing to assist with meal service without performing hand hygiene. Staff interviews confirmed a lack of adherence to hand hygiene protocols, particularly after touching their faces or other potentially contaminated surfaces. The facility's own policies and CDC guidelines require hand hygiene before and after resident contact, after glove use, and after contact with potentially contaminated surfaces. However, staff interviews and direct observations indicated that these protocols were not consistently followed. Residents with moderate cognitive impairment were not offered hand hygiene before meals, and staff did not always perform hand hygiene as required by policy during medication administration and meal service. These lapses were confirmed by both staff and residents during interviews.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were properly addressed and documented, as required by policy and regulation. Over a six-month period, concerns raised during resident council meetings, such as issues with cold food, call light response times, and dietary services, were not consistently logged as grievances, with only one grievance documented for the entire period. The Activities Director reported transcribing concerns from resident council meetings and submitting them as grievances to Social Services or the Nursing Home Administrator, but there was no evidence of follow-up or resolution communicated back to the resident council. Individual residents and their representatives also reported grievances that were not documented or resolved. One resident, who was cognitively intact and had hemiplegia, reported being treated rudely by a CNA and discussed the incident with an LPN and a Unit Manager. However, there was no record of a grievance being filed for this incident. Another resident's representative reported repeatedly raising concerns about call light response times to various staff members without receiving any resolution or follow-up. Similarly, a third resident's representative stated that concerns discussed with staff and the administrator were not addressed or followed up on, and no grievances were logged for these issues. Interviews with staff responsible for grievance management confirmed that grievances were not consistently logged or tracked for the concerns raised by residents and their representatives. The Social Services staff member acknowledged that grievances should have been written for the incidents described but were not. The facility's grievance policy outlines a process for logging, investigating, and resolving grievances, including prompt follow-up and written decisions, but this process was not followed in the cases reviewed. As a result, the facility did not ensure that residents' rights to voice grievances without discrimination or reprisal were honored, nor did it make prompt efforts to resolve grievances as required.
Failure to Provide Required Transfer/Discharge Documentation and Notification
Penalty
Summary
The facility failed to properly document and notify residents and their representatives regarding transfers or discharges, as required. For one resident with severe cognitive impairment and multiple mental health diagnoses, there was no documentation in the medical record of notifications to the resident or their representative when the resident was transferred to the hospital. The required Nursing Home Transfer and Discharge Notice (AHCA Form 3120-0002) was not found in the resident's records, nor was there evidence that the notice was given or mailed to the resident or their representative. Interviews with facility staff confirmed that the notice was not provided to residents or their representatives, but only faxed to the Ombudsman monthly. Another resident, with a history of cardiac and vascular conditions, was discharged home, but the discharge summary and instructions were incomplete and unsigned. The discharge documentation lacked essential information such as the primary physician, contact information for home health and medical equipment providers, and details on appointments, medication reconciliation, and disease management. There was also no evidence that the required transfer and discharge notice was present in the resident's records or that any information was provided to the resident upon discharge, as confirmed by the DON after reviewing the records.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment for residents by not securing accident hazards and not providing adequate supervision. Surveyors observed an unsecured and hot steam table in the North Wing Dining Room, with both entry doors open and unlocked, allowing residents unrestricted access to the steam table during meal service. Staff interviews confirmed that the steam table remained on and hot throughout breakfast and lunch, and the door meant to separate residents from the steam table was not consistently closed or locked. Additionally, two restrooms in the main hallway were found to lack emergency call cords near the toilets, despite being accessible to residents. Further deficiencies were identified regarding the storage of hazardous chemicals. On the Happy Trails unit, an unlocked cabinet in the dining/activity room contained a spray bottle of odor eliminator, and in the North Wing dining room, another unlocked cabinet contained a bottle of ant, roach, and fly spray. Both cabinets were accessible to residents at the time of observation. The DON acknowledged that these cabinets should have been locked to prevent resident access to hazardous substances. The facility also failed to provide required one-to-one supervision for a resident with a history of behavioral disturbances, including aggression and exit-seeking behaviors. Staff assigned to supervise the resident left the resident unattended in their room, contrary to physician orders and the resident's care plan, which called for continuous one-to-one supervision. The DON confirmed that staff should have remained within sight and close enough to intervene as needed. The resident's record indicated a history of agitation, aggression, and a prior incident of resident-to-resident abuse.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications throughout the facility. Observations revealed that medication carts contained expired, undated, and loose medications, including vials of Albuterol/Ipratropium nebulizer medication not stored in their original packaging, an unlabeled vial without a resident name, and open bottles of Latanoprost ophthalmic drops and liquid protein that were not dated. Additional findings included loose pills and expired medications in medication carts, as well as expired Bisacodyl suppositories and vancomycin IV bags in the medication storage room. Staff interviews confirmed that nurses are responsible for cleaning their own carts, but expired and loose medications were still present. Controlled substances were not properly secured, as locked narcotic boxes in medication refrigerators were attached to removable shelves, making them unremovable as required. An emergency drug kit containing Lorazepam, a controlled substance, was also not securely attached in the refrigerator. CPR carts on two halls were found unlocked and contained glucose gel, and staff confirmed that all nurses have keys to these carts. Additionally, medications were observed left unsecured on top of medication carts and in resident rooms, including antacid tablets and an antibiotic vial at bedside, despite no residents being approved for self-administration of medications. Facility policy requires all drugs and biologicals to be stored in locked compartments and under proper conditions, with controlled substances in separately locked, permanently affixed compartments. The policy also mandates that medications must be under direct observation or locked during medication passes, and that expired or unused medications are to be routinely removed. Despite these policies, surveyors found multiple instances where medications were not properly labeled, stored, or secured, and staff interviews confirmed lapses in adherence to these protocols.
Incomplete Discharge Documentation and Unfunctioning QAPI Oversight
Penalty
Summary
The facility failed to ensure it had a functioning Quality Assurance and Performance Improvement (QAPI) / Quality Assurance and Assurance (QAA) process that was actively reviewing quality deficiencies and ensuring corrective plans were fully implemented. During the revisit survey, the facility was recited at F628 related to discharge process concerns, and the survey findings showed that the facility had not comprehensively implemented its plan of correction for discharge record deficiencies identified during the prior annual survey. The report states that the facility held QAPI meetings on 08/15/2025, 08/22/2025, and 09/19/2025, and that prior citations from the earlier survey were discussed. The NHA stated staff education had been completed and that the Medical Director was present for the meetings, but also acknowledged concerns with the current SSD not accomplishing routine job duties. The facility policy required the QAA Committee to develop and implement plans of action to correct identified quality deficiencies and to regularly review and analyze data, yet the survey found the discharge-related deficiencies remained unresolved. The discharge record issues involved three residents reviewed during the revisit. Resident #25 had diagnoses including asthma, hypertension, UTI, and anxiety disorder, and had intact cognition with a BIMS score of 15. Resident #26 had diagnoses including a history of falling, hypertension, and depression, also with a BIMS score of 15. Resident #27 had diagnoses including a neck fracture, injury of muscles and tendons, and a history of falling, with a BIMS score of 14. For all three residents, the Nursing Home Transfer and Discharge Notice forms were incomplete: physician/designee signatures were blank, resident or representative signatures were blank, and required dates were left blank. For Resident #27, the physician order also showed a family signature but no resident signature. The NHA stated the forms were supposed to be signed two days before discharge and confirmed they should have been dated and signed, but the records reviewed did not contain completed discharge documentation.
Failure to Maintain Resident Dignity During Meal Service
Penalty
Summary
The facility failed to maintain resident dignity during meal service on the East Wing, as evidenced by multiple observations and staff interviews. Residents seated together at dining tables did not receive their meal trays at the same time, resulting in some residents watching others eat or waiting extended periods for their own meals. In one instance, a resident who was asleep at the table awoke and consumed another resident's drink and ice cream while no staff were present in the dining room. Another resident was observed sitting with a half-eaten lunch and a blanket over his head, still at the table more than an hour after the meal had ended. Additionally, a resident was seen waiting outside her room for her meal tray while her roommate had already received hers, and other residents at a table received their trays several minutes apart. Staff interviews revealed a lack of training and awareness regarding the importance of serving meals simultaneously to residents seated together. CNAs and nursing staff indicated that meal trays are delivered based on room order and not coordinated for those dining together, and the kitchen staff were not informed about which residents eat in the dining room. The DON acknowledged that staff should be aware of the need to serve meals together and agreed that the observed practices were dignity concerns. Furthermore, a nurse was observed administering eye drops to a resident at the dining table, which was confirmed by the DON as inappropriate. The facility's policy on promoting and maintaining resident dignity was not followed, as staff actions did not ensure respect and dignity during meal times.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed, resulting in a deficiency related to resident care planning and transition.
Failure to Provide Adequate ADL Assistance for Grooming and Hygiene
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were completed for three residents, specifically in the areas of grooming, nail care, haircuts, and showers. One resident was observed with unkempt and matted hair, overgrown yellow fingernails with black debris, and expressed a desire for assistance with hair brushing and nail trimming. This resident was assessed as cognitively intact and dependent on staff for bathing and personal hygiene, with a care plan indicating the need for staff assistance in these areas. Despite these needs, the resident's grooming and hygiene were not adequately maintained. Another resident reported dissatisfaction with the length of their hair and the lack of available haircuts, noting that a beautician had not been present for several weeks. Staff interviews confirmed that the facility previously had a beautician who provided regular haircuts, but due to the beautician's absence, hair care services had lapsed. The process for residents to request haircuts was described, but it was also acknowledged that no beautician was currently available, and efforts to secure a replacement were ongoing. A third resident was observed with significant facial hair and stated a preference for being shaved, which was not consistently provided. Documentation and interviews revealed inconsistencies in the provision and recording of shaving assistance, with some shower logs lacking information on whether shaving was completed or if refusals occurred. The resident's care plan and progress notes did not address shaving needs or refusals, despite the resident's moderate cognitive impairment and dependence on staff for personal hygiene. The facility's ADL policy requires that residents unable to perform ADLs receive necessary services to maintain grooming and hygiene, but these requirements were not met for the residents reviewed.
Failure to Ensure Monthly Pharmacist Drug Regimen Review and Irregularity Reporting
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow its developed policies and procedures for reporting irregularities identified during the drug regimen review process. This deficiency was identified during the survey based on the facility's lack of compliance with established guidelines for pharmacist review and reporting.
Failure to Support Resident's Choice to Transfer
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to self-determination by not supporting her expressed choice to transfer to another facility. The resident, who had a history of protein-calorie malnutrition, bipolar disorder, mood disorder, opioid dependence, and generalized anxiety disorder, communicated her desire to move to another facility but reported that her requests were ignored and not acted upon. The resident had a moderate cognitive impairment, as indicated by a BIMS score of 10 out of 15. There was no documentation in her progress notes or the facility's grievance log regarding her request or any follow-up actions taken by staff. Interviews with the Social Services Assistant revealed that although she was aware of the resident's wish to transfer and had discussed it with her, she did not document the conversation or any change in the resident's wishes. The facility's policy requires informing residents of their rights and documenting relevant information, but there was no evidence that the resident's request or subsequent discussions were recorded. This lack of documentation and follow-up resulted in the facility failing to promote and facilitate the resident's right to make choices about her care and living arrangements.
Deficient Grievance Process in LTC Facility
Penalty
Summary
The facility failed to ensure a functioning grievance process for three residents, as evidenced by the lack of proper documentation and follow-up on grievances. For Resident #1, the facility's grievance log showed two grievances regarding hydration preference and room cleanliness, both marked as resolved. However, a concern about missing clothing items was not properly documented or resolved. The Social Service Director (SSD) had only a post note with no specific details, and the missing items list was incomplete. The SSD offered $100 to the family verbally, but there was no documentation of this offer being made or accepted. Resident #2's grievance involved missing money and clothing items. The grievance log had incomplete documentation, lacking details about the person making the complaint and whether the grievance was resolved. The SSD confirmed that the money was replaced, but the Business Office Manager (BOM) revealed that the money was never deposited into the resident's trust account and remained in the safe. The BOM also noted discrepancies in the documentation of the money returned to the resident. For Resident #9, the grievance log showed two grievances: one about cold meals and another about broken call lights. The resolution for the cold meal grievance was not documented, and the resident confirmed that the issue persisted. The call light grievance lacked documentation of who investigated it, and while some corrective actions were noted, the resident reported no follow-up on the cold meal issue. The SSD admitted to not discussing grievances comprehensively in Quality Assurance and Performance Improvement (QAPI) meetings, indicating a systemic issue in handling grievances effectively.
Failure to Return Resident's Personal Funds Post-Discharge
Penalty
Summary
The facility failed to convey personal funds deposited with the facility within 30 days of discharge for a resident. The resident was admitted to the facility and subsequently discharged on a specified date. However, a balance of $11.00 in the resident's personal trust account was not returned. A grievance was filed regarding the missing money, but the grievance form lacked documentation of the person making the complaint, their relationship to the resident, and whether the grievance had been resolved. The Social Services Director (SSD) acknowledged the grievance but did not have documentation of the amount of money involved. The Business Office Manager (BOM) presented a receipt for $15.00 intended for the resident's trust account, which was never deposited. Instead, the money remained in the safe, and $4 was given to the resident without proper documentation or signatures. The BOM confirmed the remaining $11 was still in the safe, and the discrepancy was not resolved. The Nursing Home Administrator (NHA) indicated plans to initiate training on handling missing items and grievances, but this was not part of the deficiency itself.
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Illustrative
What surveyors actually found near you
We read the 5 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lake Placid
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vivo Healthcare Sebring | 12.1 mi | ★★★★★ | 1 | 0 |
| Palms At Sebring Nursing And Rehabilitation The | 12.6 mi | ★★★★★ | 2 | 0 |
| Oaks At Avon | 21.4 mi | ★★★★★ | 1 | 0 |
| Royal Care Of Avon Park | 23.1 mi | ★★★★★ | 1 | 0 |
| Desoto Health And Rehab | 30 mi | ★★★★★ | 7 | 0 |
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