Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 North Lake Care Center And Rehab during CMS and state inspections, most recent first.
Failure to Notify Physician of Significant Weight Loss: A resident with HF, DM2, and PVD had a 5.91% weight loss in 1 month, but the physician was not informed right away. The RD knew of the loss and requested a re-weigh, yet planned to wait until after seeing the resident and reviewing trends before notifying the MD; the MD and NP both stated they wanted to be informed as soon as staff knew of the significant weight loss.
Failure to report and resolve a resident grievance: A cognitively intact resident with assistance needs for ADLs reported that 2nd shift staff were slow to answer the call light and rude when responding. The resident said he raised the concerns multiple times to the staff member who visited his room daily, and the ambassador, DON, and Administrator were aware, but no grievance was documented in the grievance log and the DON stated she did not complete one.
A resident with mild cognitive impairment and partial/moderate ADL needs had orders for a UA with reflex to culture, CBC with diff, and BMP, but the labs were not obtained. The record also did not show that the physician was notified of the missed labs, and the DON acknowledged the omission.
Missing dialysis communication forms were identified for a resident with ESRD who received HD twice weekly. The resident’s care plan required the dialysis communication tool to be completed on dialysis days and reviewed on return, but several forms were missing and multiple post-dialysis nurse assessment sections were left incomplete. An RN acknowledged the omissions and stated the resident was expected to return with the form for post-treatment review.
Controlled substance reconciliation was not appropriately completed for two residents. For one resident, a tramadol dose documented on the MAR was not recorded on the controlled substance log, and for another resident, an oxycodone dose appeared on the controlled substance log but was not documented on the MAR. The DON acknowledged the discrepancies between medication administration and controlled substance documentation.
The facility failed to maintain policies and procedures for monthly MRR time frames and did not consistently process consultant pharmacist recommendations for two residents. One resident with COPD and major depressive disorder had trazodone reviewed for GDR, but the APRN response was never entered into the chart. Another resident with CHF, DM2, anxiety, and major depressive disorder had pantoprazole reviewed for dose reduction, but that order was also not entered, and the recommendation was not addressed in a later pharmacist report. The DON stated she kept the recommendations but did not review them, and the APRN said she assumed the DON entered the orders.
Failure to initiate behavior monitoring was identified for a resident with heart failure, DM2, and PVD who had a BIMS score of 15. The resident was started on Quetiapine for psychosis and later increased for schizoaffective disorder, but no behavior monitoring order was in place for the antipsychotic since it began, and the DON acknowledged the omission.
Unsecured Medication at Bedside: A resident with intact cognition and diagnoses including adrenal insufficiency, anxiety, and glaucoma had hydrocortisone cream left on the overbed table during two observations. The resident had not expressed a desire to self-administer medications, and the DON acknowledged the cream was at the bedside even though facility policy required medications to be stored securely and bedside medications to be locked if self-administered.
Failure to Monitor Antibiotic Use and Complete Infection Workup: A resident with dysuria, BPH, and UTI risk was treated with oral and then IV antibiotics, but ordered urine culture and labs were not completed as ordered. The chart did not show fever, pain, or urinary difficulty, and the NP acknowledged the missing culture and labs; the DON and ICP stated the resident did not meet criteria for antibiotic stewardship and the antibiotic was given because it was ordered.
A resident with severe cognitive impairment eloped from a facility through an unsecured second-floor door. The resident, identified as at risk for elopement, was able to exit due to inadequate supervision and security measures. The resident was found 0.3 miles away after crossing a busy road and railroad tracks. The facility's elopement risk evaluation and care plan interventions were not effectively implemented, and the door alarm was not audible to staff.
The facility failed to provide adequate housekeeping and maintenance services, resulting in a failure to maintain a clean, comfortable, sanitary, and homelike environment in 9 of 30 rooms and the Community Shower Room. Observations included clogged sinks and toilets, unsecured faucets, missing drain plugs, dirty basins and faucets, worn overbed tables, duct tape on air conditioning units, loose toilet seat rails, and debris under beds. The Community Shower Room had an odor similar to sewage.
The facility failed to follow its Enhanced Barrier Precautions (EBP) policies for 17 of 18 residents, as PPE was not available at or outside residents' doors. Additionally, the laundry rooms were inadequately maintained, with peeling paint, accumulated dirt, and debris in sorting bins, and foreign matter in industrial dryers, posing a risk of cross-contamination.
The facility failed to ensure that a resident received showers according to her preferences and the facility's schedule. Despite being cognitively intact and expressing a desire for weekly showers, the resident was rarely offered showers, and the facility's documentation did not specify whether she received a bath or a shower.
The facility failed to maintain the fingernails of two residents, leading to dissatisfaction and delayed care. Staff interviews revealed confusion about responsibility and restrictions regarding nail trimming, contributing to the deficiency.
The facility failed to ensure the safe transfer of a resident, resulting in skin damage, and did not provide necessary safety devices for residents while smoking. A resident sustained a 4-inch cut during a Hoyer lift transfer performed by a CNA alone, despite the expectation of two staff members for such transfers. Additionally, another resident was observed smoking without a required smoking apron on multiple occasions, contrary to the facility's smoking policy.
A facility failed to assess a resident for bed rail risks, obtain physician's orders, and initiate a care plan for bed rail use. The resident, with multiple diagnoses and dependent on staff for mobility, requested bed rails to prevent falls, but the facility did not follow its policy for evaluation and documentation.
The facility failed to follow physician's orders for medication administration timing for three residents, leading to late administration and potential drug interactions. One resident received two medications with a potential interaction at the same time, another reported inconsistent timing for night medications, and a third experienced late administration of ADHD medication, affecting sleep.
A pharmacist failed to identify a timing issue with a possible drug-to-drug interaction for a resident receiving both mirtazapine and alprazolam. The medications were administered together despite orders to separate them, which was overlooked in monthly reviews, potentially causing added sedative effects, CNS depression, and respiratory depression.
The facility failed to monitor behaviors as ordered by the physician for five residents on psychotropic medications. Multiple instances of missing documentation were found in the Behavior Monitoring Flow Sheets for April and May 2024. The Director of Nursing and Regional Clinical Consultant acknowledged these deficiencies.
A resident with multiple diagnoses left the facility and did not return as anticipated. The facility failed to document the resident's discharge accurately and promptly, leading to confusion about the resident's status. Staff interviews revealed attempts to contact the resident and involve the police, but these actions were not documented in the resident's chart until much later.
The facility failed to offer, educate, and obtain consent for the pneumonia vaccine for five residents. Documentation and education regarding the benefits and potential side effects of the vaccine were not provided as required by the facility's policy. The DON acknowledged the oversight, which was partly due to a misunderstanding of CDC guidelines.
The facility failed to maintain and inspect bed rails for a resident, leading to bed rails not staying in a raised position. The Director of Maintenance was unaware of the issue and could not provide documentation of regular inspections, despite the facility's policy requiring routine checks and reporting to the QAPI committee.
The facility failed to ensure the accessibility and functionality of call bells for two residents. One resident's call device was found on the floor and later not in sight, while another resident's call bell system was not functioning, requiring him to rely on his roommate for assistance. Staff were aware of the issues but did not resolve them in a timely manner.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to inform the physician of a significant weight loss for one of three residents reviewed for nutrition. Resident #6 was admitted with diagnoses including heart failure, type 2 diabetes mellitus, and peripheral vascular disease, and had a BIMS score of 15 on the quarterly MDS assessment, indicating the resident was cognitively intact. The facility’s policy defined a 1-month weight loss of 5% as significant, and the resident’s weight decreased from 237.5 pounds on 08/04/25 to 223 pounds on 09/02/25, a 5.91% loss. The resident’s re-weight was not in the electronic health record. Staff interviews showed the RD was aware of the weight loss and requested a re-weigh, but stated she had not yet met the resident and would notify the physician only after talking with the resident and reviewing the trend. She also stated it was a long time to wait a week to notify the physician. The Medical Director stated he would want to be informed of a resident’s significant weight loss right away, and the Nurse Practitioner stated she would have liked to know as soon as staff knew the resident had a significant weight loss.
Failure to Report and Resolve Resident Grievance
Penalty
Summary
The facility failed to report and resolve a grievance for Resident #11 regarding concerns about care and call light response time on 2nd shift. Resident #11 was admitted on [DATE], had a comprehensive assessment documenting that he was cognitively intact, and was care planned on 04/23/25 for self-care deficit with dressing, grooming, and bathing, with staff assistance as needed due to generalized weakness and limited endurance. During interviews on 09/08/25 and 09/10/25, Resident #11 stated he had concerns that 2nd shift staff were slow to respond to his call light and were rude when responding, and he said he had reported these concerns multiple times to the staff member who visited his room almost every morning without receiving a response or seeing a change. The Director of Housekeeping, who served as the resident's ambassador, acknowledged the resident's concerns and stated he had brought them to the DON and Administrator during morning meetings about a month earlier. Review of the grievance log did not show a grievance for these concerns within the past 3 months, and the DON acknowledged awareness of the concerns but stated she did not complete a grievance for Resident #11.
Missed Ordered Labs and No Physician Notification
Penalty
Summary
The facility failed to obtain ordered labs and failed to notify the physician that the labs were missed for Resident #54. Record review showed the resident was admitted to the facility and had a comprehensive assessment documenting mild cognitive impairment and partial/moderate assistance needs with activities of daily living. An order dated 09/03/25 required a urinalysis with reflex to culture, CBC with differential, and BMP in the morning, but the urine culture, CBC, and BMP were not conducted or obtained. The resident's record also did not show any indication that the physician was notified of the missed labs. During interview, the DON acknowledged the labs were missed.
Missing Dialysis Communication Forms
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met when the facility failed to complete and maintain dialysis communication forms for Resident #3, who was admitted with End Stage Renal Disease (ESRD), had moderate cognitive deficit, required supervision for activities of daily living, and received dialysis. The resident’s care plan identified dialysis on Tuesday and Saturday and included an intervention to complete the dialysis communication tool on dialysis days and review it upon return from dialysis. Record review showed missing dialysis communication forms for 08/12/25, 08/30/25, and 09/02/25, and the section for the facility nurse to complete when the resident returned from dialysis was not completed for 08/16/25, 08/19/25, 08/23/25, and 08/26/25. During interview, the resident’s RN acknowledged the missing forms and stated the resident leaves the facility with the form to go to dialysis and is expected to return with it for post-treatment review and assessment.
Controlled Substance Reconciliation Discrepancies
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to appropriately reconcile controlled medications for 2 of 4 sampled residents reviewed for medication reconciliation. The facility policy for controlled substances stated that controlled substance inventory is monitored and reconciled to identify loss or potential diversion, and that reconciliation includes records of personnel access and usage, MARs, declining inventory records, and destruction, waste, and return-to-pharmacy records. For one resident, the controlled substance log for tramadol 100 mg tablets showed 21 tablets remaining, and the dosing card also had 21 tablets remaining, but the MAR showed a dose administered that was not recorded on the controlled substance log. For another resident, the controlled substance log for oxycodone IR 15 mg showed 9 tablets remaining, and the dosing card also had 9 tablets remaining, but the MAR did not contain an entry for a dose listed on the controlled substance log. The DON stated there should not be discrepancies with controlled substance administration and documentation and agreed to investigate the discrepancies identified by the surveyor.
Failure to Track and Enter Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to develop and maintain policies and procedures for the monthly drug regimen review process, including time frames for the different steps in the process, for two sampled residents receiving medications for unnecessary medication review. The facility’s policy on medication regimen reviews stated that the consultant pharmacist reviews the resident’s medical record to identify and report medication-related problems and irregularities, and that if the physician does not provide a timely or adequate response, the consultant pharmacist contacts the Medical Director or Administrator. The facility’s tapering/GDR policy stated that psychotropic medications should have gradual dose reduction attempts under specified circumstances, including within the first year after admission or initiation, unless clinically contraindicated. For one resident with diagnoses including COPD with exacerbation and recurrent moderate major depressive disorder, the record showed trazodone 100 mg at bedtime was ordered and later discontinued, then restarted, and later increased to 150 mg at bedtime. A consultant pharmacist recommendation dated 05/06/25 stated the resident had been taking trazodone 100 mg every bedtime since 11/16/24 without a GDR and asked whether a dose reduction could be attempted. The APRN response dated 05/09/25 documented a decrease to 75 mg at bedtime for depression, but the order to attempt the GDR was never entered into the resident’s chart. The DON stated the recommendations were kept by her, but she did not review them, and that the physician or nurse practitioner was to enter their own orders. For another resident with diagnoses including acute chronic diastolic CHF, type 2 diabetes mellitus, generalized anxiety disorder, and major depressive disorder, the record showed pantoprazole 40 mg at bedtime was ordered and later discontinued, with a later order for pantoprazole 20 mg at bedtime. A consultant pharmacist recommendation dated 06/06/25 stated the resident had been taking pantoprazole 40 mg at bedtime since 02/19/25 without a dose reduction and suggested a trial reduction to 20 mg at bedtime; the APRN response dated 06/11/25 was to reduce the dose to 20 mg daily. However, the order to reduce the dose was never entered into the resident’s chart, and the recommendation was not addressed in the July 2025 pharmacist report. The DON stated she did not review the responses, and the APRN stated she assumed the DON entered the orders into the chart.
Failure to Initiate Behavior Monitoring for Antipsychotic Medication
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met for one of five sampled residents reviewed for unnecessary medications. Resident #6 was admitted with diagnoses including heart failure, type 2 diabetes mellitus, and peripheral vascular disease, and the quarterly MDS dated 06/25/25 documented a BIMS score of 15, indicating intact cognition. Physician orders showed Quetiapine Fumarate 25 mg twice daily was started on 09/05/25 for psychosis, and the dose was increased on 09/10/25 to 50 mg at bedtime related to schizoaffective disorder. Review of the physician orders found no behavior monitoring order for the antipsychotic medication since it was started, and the DON acknowledged during interview on 09/11/25 that behavior monitoring had not been done for the medication.
Unsecured Medication at Bedside
Penalty
Summary
The facility failed to secure medications at all times for 1 of 21 sampled residents when hydrocortisone cream 1% was observed on the resident’s overbed table next to the bed on two separate observations. The resident had diagnoses including unspecified adrenocortical insufficiency, anxiety disorder, and unspecified glaucoma, and the MDS documented a BIMS score of 15, indicating intact cognitive response. The resident’s record also included orders for topical creams and ointments for eczema and dry skin, and two self-administration assessments documented that the resident did not express a desire to self-administer medications or treatments. Facility policy stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner, and that residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe. During interview, the resident stated the hydrocortisone cream was for eczema. The DON stated that residents could have medications at the bedside only if assessed as safe for self-administration and that the medications would need to be kept locked. The DON also acknowledged the resident had hydrocortisone cream on the overbed table and removed it, stating the resident had a different cream ordered for the same issue.
Failure to Monitor Antibiotic Use and Complete Ordered Infection Workup
Penalty
Summary
The facility failed to have an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for a resident with infection concerns. Resident #54 was admitted with mild cognitive impairment, partial/moderate assistance needs for activities of daily living, dysuria, and benign prostatic hyperplasia, and was care planned for alteration in elimination with frequent bladder and bowel incontinence, impaired mobility, difficulty with urine stream, and risk for UTI. The resident was observed by the surveyor and later interviewed while in bed with a new IV line in the right arm, and stated the line was placed that morning for some kind of infection. Record review showed an order for urinalysis with reflex to culture, CBC, and BMP, along with ciprofloxacin for UTI, but the urine culture, CBC, and BMP were not obtained as ordered. Later orders were written for a mid-line and IV antibiotics for UTI/pyelonephritis, with additional urinalysis, culture, CBC, and BMP orders. The chart did not show indications of pain, difficulty urinating, or increased temperature, and staff stated the resident had not complained of pain. The NP acknowledged the initial urine culture and ordered labs were not completed, and the DON and ICP stated the resident did not meet criteria for antibiotic stewardship and that the antibiotic was given because the NP ordered it.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to provide appropriate supervision to a resident assessed as at risk for elopement, resulting in the resident exiting the facility through an unsecured door on the second floor. The resident, who had severe cognitive impairment with a BIMS score of 00, was able to leave the facility on a Saturday evening when there were no staff present in the area. The resident was found approximately 0.3 miles away in an industrial area, having crossed a busy road and active railroad tracks. The resident's care plan, initiated a few days before the incident, identified the resident as having a potential for elopement due to cognitive impairment and wandering behavior. Despite this, the facility's elopement risk evaluation and care plan interventions were not effectively implemented. The resident was able to navigate through the facility and exit through a door that was not secured with a magnetic lock, as it was not considered a resident area. The alarm on the door was not audible to staff, and there were no staff present to respond to the alarm. Interviews with facility staff revealed that the resident had been seen in the upstairs area the previous evening and redirected, but this information was not communicated effectively. The facility's investigation determined that the second floor was not identified as a risk area, and the door was not secured in a manner consistent with other doors in the facility. The lack of supervision and inadequate security measures contributed to the resident's ability to elope from the facility.
Removal Plan
- An Ad hoc QAPI with Root Cause Analysis was performed with the IDT team, including: the Administrator, the Regional Director of Operations, the Regional Clinical Director, the Regional Maintenance Director. QAPI meetings were scheduled for the last Thursday of each month.
- All current residents' Elopement Assessment were reviewed and updated by nursing. There were no newly identified residents at high risk of elopement.
- Staff education was initiated to include Abuse and Neglect policy and procedure, Elopement policy and procedure, and new processes of closing the dining room door when the room is not in use.
- Elopement drills were conducted daily up to every shift daily to continue on for 14 days, then weekly for 4 weeks, then monthly thereafter.
- The Senior Safety and Technology company installed Maglock (mag) on the second-floor exit door next to HR department office and the door between the unit and the Activities/Dining room for added security.
- Education on the Identifying residents with behavioral symptoms that put the residents at risk for elopement was initiated.
- Daily audits of the doors and alarms were initiated and the results reported to QAPI/QA Committee of the findings.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services, resulting in a failure to maintain a clean, comfortable, sanitary, and homelike environment in 9 of 30 rooms and the Community Shower Room. Specific deficiencies observed included clogged sinks and toilets, unsecured faucets, missing drain plugs, dirty basins and faucets, worn and exposed particle board on overbed tables, lack of overbed tables, duct tape covering screens on air conditioning units, loose toilet seat rails, and accumulation of debris under beds. Additionally, the Community Shower Room had an odor similar to sewage emanating from the shower and sinks. These observations were made during an environmental tour conducted with the Director of Maintenance, who acknowledged understanding of the findings. The deficiencies indicate a lack of proper maintenance and housekeeping services, compromising the residents' right to a safe, clean, comfortable, and homelike environment. The issues identified could potentially impact the residents' daily living and overall well-being.
Infection Control and Laundry Room Maintenance Deficiencies
Penalty
Summary
The facility failed to follow its own policies and procedures for Enhanced Barrier Precautions (EBP) for 17 of 18 residents, as evidenced by the absence of gowns at or outside the residents' doors. The Director of Nursing (DON) confirmed that the facility follows CDC guidelines, which require PPE (gowns and gloves) to be located at the residents' doors. However, observations revealed that multiple rooms with EBP signs did not have the required gowns available, and the existing PPE was inadequately distributed across divisions, with some divisions lacking the necessary PPE entirely. This failure was observed despite the DON's assertion that PPE was available on blue linen carts and in central supply rooms, indicating a significant lapse in adherence to infection control protocols. Additionally, the facility's laundry rooms were found to be inadequately maintained, posing a risk of cross-contamination. The dirty laundry room had peeling paint with loose edges, which could contaminate the laundry. Sorting bins in the dirty laundry area had accumulated dirt and refuse beneath their false bottoms, and similar issues were found in bins used for clean laundry. The clean laundry folding area also had debris under the false bottoms of bins, and workers were observed mishandling potentially contaminated items. Furthermore, the industrial dryers had foreign matter adhering to the drum surfaces, and the floors in both the dirty and clean laundry areas had large areas of peeling paint, further risking contamination of clean laundry. These deficiencies highlight significant lapses in the facility's infection prevention and control program, particularly in the areas of PPE availability and laundry room maintenance. The observations and interviews conducted during the survey indicate a failure to adhere to established policies and CDC guidelines, thereby compromising the facility's ability to prevent the spread of multi-resistant organisms (MDROs) and maintain a clean environment for residents and staff.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that Resident #19 received showers according to her preferences and the facility's schedule. Resident #19, who was cognitively intact with a BIMS score of 15, expressed that she was rarely offered showers and would like to have them at least weekly. The facility's documentation indicated that her bathing schedule was set for Mondays and Thursdays during the 3 PM to 11 PM shifts, but it did not specify whether she received a bath or a shower. Interviews with staff revealed that there was a shower book and that refusals were to be documented in the EMR after consulting with a nurse. However, the documentation did not differentiate between a bath and a shower, and there was no clear record of whether Resident #19's preferences were being honored. During interviews, staff confirmed the process for documenting showers but acknowledged that the records did not specify whether a bath or a shower was provided. This lack of specificity in the documentation and the failure to offer showers as per the resident's preference led to the deficiency. The facility did not ensure that Resident #19's right to choose between a bath and a shower was respected, as required by her comprehensive Admission MDS.
Failure to Maintain Residents' Fingernails
Penalty
Summary
The facility failed to maintain the fingernails of two residents, Resident #45 and Resident #48, as observed and reported during a survey. Resident #45 was noted to have fingernails extending about 1/2 inch past his fingertips on both hands. Despite expressing a desire to have his nails trimmed, the resident's fingernails remained untrimmed for several days until they were finally addressed. Similarly, Resident #48 had fingernails extending at least 1/2 inch beyond his fingertips and expressed dissatisfaction with their length. The resident mentioned having to pay for nail trimming services in the past and indicated that the facility staff had not trimmed his nails despite his requests. His nails were eventually trimmed after several days of waiting and asking the staff for assistance. Interviews with staff revealed a lack of clarity regarding the responsibility for nail care. A Certified Nursing Assistant (CNA) indicated that while the Activities staff typically performed nail trimming, the responsibility for ensuring it was done fell to the nurses and CNAs. The CNA also mentioned a belief that they were not allowed to trim the fingernails of diabetic residents, although this restriction was not clearly stated in the facility's policy. This confusion and lack of timely action led to the deficiency in maintaining proper nail care for the residents.
Failure to Ensure Safe Transfers and Smoking Safety
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in skin damage. Resident #18, who has multiple diagnoses including quadriplegia and contractures, was being transferred via a Hoyer lift by a CNA with the assistance of the resident's mother. During the transfer, the resident sustained a 4-inch cut on the left elbow. The Director of Nursing (DON) confirmed that the CNA performed the transfer alone, despite the facility's expectation that two staff members should be involved in such transfers. The facility does not have a formal policy requiring two staff members for Hoyer lift transfers, which contributed to the incident. Additionally, the facility failed to provide necessary safety devices for residents while smoking. Resident #80, who has a history of nicotine dependence and other medical conditions, was observed smoking without a required smoking apron on multiple occasions. The facility's smoking policy mandates the use of smoking aprons to ensure safety, but the aprons were not provided to the residents. Interviews with staff revealed that the aprons were kept in the Activities closet and were not consistently made available to residents, leading to lapses in safety measures. These deficiencies highlight lapses in the facility's adherence to safety protocols, both in the context of resident transfers and smoking safety. The lack of proper supervision and equipment contributed to the incidents involving Resident #18 and Resident #80, respectively. The facility's failure to follow established safety practices resulted in harm and potential risk to the residents involved.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for the risks associated with the use of bed rails, obtain physician's orders for the use of bed rails, and initiate a care plan for the use of bed rails for one resident. The facility's policy on bed safety and bed rails, revised in August 2022, outlines the necessary steps for evaluating and implementing bed rails, including an interdisciplinary evaluation, risk assessment, and obtaining input from the resident and/or responsible party. However, these steps were not followed for Resident #134, who was observed using half side rails on the bed without a documented assessment, care plan, or physician's orders. Resident #134, who was admitted with multiple diagnoses including anemia, hypertension, chronic lung disease, and dependence on renal dialysis, had a BIMS score indicating cognitive intactness. The resident was dependent on staff for transfer and bed mobility and was frequently incontinent of urine and always incontinent of bowel. Despite the resident's request for bed rails to prevent falling out of bed, the facility did not conduct the required risk assessment or obtain the necessary physician's orders and care plan documentation for the use of bed rails.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to follow physician's orders related to the timing for administration of medication for three residents. Resident #19 was receiving two medications, mirtazapine and alprazolam, which had a potential drug interaction and were ordered to be administered at different times. However, both medications were administered at 9:00 PM, contrary to the physician's order. This error was identified during a side-by-side record review and interview with the LPN/Unit Manager, who acknowledged the mistake in scheduling the alprazolam order upon the resident's admission. Resident #63, who was cognitively intact, reported not receiving his night medications at the prescribed bedtime of 9:00 PM. Instead, the medications were administered at varying times, ranging from 6:30 PM to after midnight. The review of the Medication Administration Record (MAR) confirmed that the medications were often given late, with timestamps showing administration times well past the scheduled 9:00 PM slot. The Consultant Nurse agreed with these findings upon review. Resident #68, who had diagnoses including Generalized Anxiety Disorder and ADHD, also experienced issues with medication timing. The resident's ADHD medication, Dextroamphetamine Sulfate, was ordered to be administered three times a day at specific times. However, the medication was given more than one hour late on nine occasions out of 45 opportunities, with one instance being over two hours late. The resident reported that the late administration interfered with her sleep. The Director of Nursing and the Regional Clinical Consultant acknowledged the discrepancies in medication administration times during an interview.
Pharmacist Overlooked Drug Interaction Timing Issue
Penalty
Summary
The pharmacist failed to identify a timing issue with a possible drug-to-drug interaction for Resident #19. The resident was admitted with diagnoses including major depression and anxiety disorders and was receiving both an antidepressant (mirtazapine) and an antianxiety medication (alprazolam). The order for alprazolam specifically stated it should not be administered with mirtazapine. However, the Medication Administration Record (MAR) showed that both medications were being administered at 9:00 PM, contrary to the order which scheduled alprazolam for 6:00 PM. This error was identified during a side-by-side record review and interview with a Licensed Practical Nurse (LPN)/Unit Manager, who confirmed the mistake was made upon the resident's admission. Pharmacy reviews from January 2024 through April 2024 did not include any recommendations for Resident #19, indicating that the Consultant Pharmacist overlooked the issue. During a phone interview, the Consultant Pharmacist acknowledged the oversight and explained that administering both medications together could cause added sedative effects, CNS depression, and respiratory depression. This deficiency highlights a failure in the monthly drug regimen review process, as the pharmacist did not identify the critical timing issue and potential drug interaction for the resident.
Failure to Monitor Behaviors as Ordered for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to monitor behaviors as ordered by the physician related to psychotropic medications for five of six sampled residents. Resident #19 was admitted with orders to monitor behaviors twice daily and document interventions and outcomes, but there were multiple instances in May and April 2024 where this monitoring was not performed. Specifically, there were 6 out of 29 shifts in May and 20 out of 60 shifts in April where behavior monitoring was not documented for Resident #19. Resident #35, who was admitted with diagnoses including Lymphedema, Major Depressive Disorder, and Anxiety Disorder, also had lapses in behavior monitoring. The Behavior Monitoring Flow Sheet for May 2024 showed that interventions, medication management, and side effects were not documented for 8 out of 30 opportunities. Similarly, Resident #68, with diagnoses including Generalized Anxiety Disorder and Major Depressive Disorder, had 15 out of 30 opportunities in May 2024 where behavior monitoring was not documented. Resident #64, admitted with Anxiety Disorder and Unspecified Psychosis, had severe cognitive impairment and also experienced lapses in behavior monitoring. The Behavior Monitoring Flow Sheet for May 2024 revealed that interventions, medication management, and side effects were not documented for 20 out of 45 opportunities. Lastly, Resident #236, with diagnoses including Dementia and Major Depressive Disorder, had 2 out of 3 opportunities in May 2024 where behavior monitoring was not documented. The Director of Nursing and Regional Clinical Consultant acknowledged these deficiencies during an interview on May 16, 2024.
Failure to Ensure Accurate Documentation of Resident Discharge
Penalty
Summary
The facility failed to ensure the accuracy of records for a resident, leading to a deficiency in maintaining accurate documentation of the resident's discharge. The resident, who had diagnoses including Anxiety Disorder, Alcohol Abuse, and Nicotine Dependence, left the facility after signing out and did not return as anticipated. Despite the resident's clear communication that he would not return until a later date, the facility did not document this information accurately in the resident's medical record until much later. Interviews with staff revealed that the resident had a history of signing out and returning the same day, but on this occasion, he informed the staff that he would not return until the following Monday. The staff attempted to contact the resident and his family, and even involved the police for a wellness check, but there was no immediate documentation of these actions in the resident's chart. The lack of timely documentation led to confusion about the resident's discharge status. The MDS Director initially coded the discharge as 'return anticipated' and only changed it to 'return not anticipated' after receiving supporting documentation much later. The Administrator and other staff acknowledged the absence of proper documentation in the resident's chart regarding the resident leaving against medical advice (AMA) and the subsequent actions taken by the facility. This failure to document accurately and promptly resulted in a deficiency in maintaining the resident's medical records according to accepted professional standards.
Failure to Offer and Document Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer, educate, and obtain consent for the pneumonia vaccine for five residents. Specifically, Residents #53 and #18 did not have Pneumococcal consents or refusals documented, and none of the five residents had evidence of being offered the vaccines or provided with education. The facility's policy requires that residents or their legal representatives receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine, and that this education is documented in the resident's medical record. However, this was not adhered to in the cases reviewed. During the review, it was found that Resident #53 had documentation of refusal for the Influenza vaccine but no consent or refusal for the Pneumonia and COVID-19 vaccines. Similarly, Resident #18 had consent for the Influenza vaccine but no other consents. The Director of Nursing (DON) acknowledged the lack of documentation and education, mistakenly believing that the CDC guidelines only required the Pneumonia vaccine for individuals of a certain age. This misunderstanding contributed to the failure to offer and document the necessary vaccinations and education for the residents.
Failure to Maintain and Inspect Bed Rails
Penalty
Summary
The facility failed to ensure bed rails were maintained in working condition and inspected for fitness and function for one of the two sampled residents reviewed for bed rails. The facility's policy required maintenance staff to routinely inspect all beds and related equipment to identify risks and problems, including potential entrapment risks. However, the Director of Maintenance was unaware of the concerns with the bed rails not staying in a raised position for the resident. The resident, who was cognitively intact and dependent on staff for transfer and bed mobility, reported that the bed rails had not stayed in a raised position since being admitted. The Director of Maintenance later fixed the bed rails by readjusting and tightening the holding mechanism and pin, but there was no documentation of regular inspections performed as required by the facility's policy. The resident's care plan included the use of bed rails as an enabler for bed mobility, and the resident had multiple diagnoses, including anemia, hypertension, chronic lung disease, and dependence on renal dialysis. Despite the facility's policy stating that maintenance staff should provide a copy of inspections to the administrator and report results to the QAPI committee, the Director of Maintenance was unable to generate documentation of audits or maintenance of the side rails and bed from the electronic system. This lack of documentation and awareness of the bed rail issues led to the deficiency identified by the surveyors.
Inaccessible and Non-Functional Call Bells for Residents
Penalty
Summary
The facility failed to ensure the accessibility and functionality of call bells for two residents. For Resident #9, observations revealed that the call device was on the floor next to the bed and later not in sight when the resident was in a wheelchair. Interviews with the resident confirmed that she was unaware of the call device's location, indicating a lack of accessibility to the call system. The resident's care plan emphasized the need for assistance with personal care tasks and mobility, but the call system's inaccessibility hindered this support. For Resident #53, the call bell system was not functioning, and the resident had to rely on his roommate to call for assistance. The resident had been waiting for a new bed for two months due to the malfunctioning call bell. The Maintenance Director was unaware of the issue until the surveyor's interview, and there was no documentation in the electronic work record system. The Maintenance Director attempted to fix the device but was unsuccessful, and a new device was arranged for delivery. Interviews with staff confirmed awareness of the problem but indicated a lack of timely resolution and proper documentation.
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What surveyors actually found near you
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lake Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edward J Healey Rehabilitation And Nursing Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Rehabilitation Center Of The Palm Beaches, The | 2.5 mi | ★★★★★ | 0 | 0 |
| Prosper Health And Rehabilitation Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Gardens Court | 3.8 mi | ★★★★★ | 6 | 0 |
| Lakeside Health Center | 4 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.