Below average — CMS composite of the measures below.
The next survey window likely opens 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 Lake Lodge Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple serious conditions, including acute respiratory failure, CHF, pulmonary edema, diabetes, and obesity, had no order or care plan for weight loss medication or self-administration of medications. An LVN observed the resident self-injecting a syringe provided by a family member, who gave conflicting explanations that it was for anxiety, then just water, while another nurse heard it described as a weight loss medication. A CNA reported that the resident told her his family member was giving him weight loss medication, but she did not report this information to her supervisor. Other licensed staff stated they were unaware of any outside medications and would have reported such information. This failure to report occurred despite facility policy requiring all individuals to recognize and report potential abuse, neglect, or situations that may constitute neglect, resulting in the cited deficiency.
Staff failed to follow infection control procedures when a medical assistant used reusable wrist BP cuffs on multiple residents in succession without disinfecting the cuffs between uses. Over the course of a morning medication pass, the assistant obtained BP readings on eight residents with varying medical conditions, including Parkinson’s disease, CKD, diabetes, and hypertension, and with cognitive status ranging from intact to severely impaired, but only performed hand hygiene and did not clean the cuffs. In interviews, the assistant reported sanitizing cuffs only when residents had COVID, while other nursing staff and the DON stated that cuffs are required to be sanitized between each resident to prevent cross contamination, contrary to what was observed.
Insufficient RN weekend coverage was identified when review of RN time stamps showed the facility did not have an RN on duty for 8 consecutive hours on multiple weekend days. The DON said weekend RNs were scheduled for 6:00 PM to 6:00 AM with a long break before returning for the next shift, and she believed only 8 total hours of coverage were needed. The ADM stated he understood the RN day schedule differently, and the facility had no nurse staffing policy.
Unlocked Treatment Cart with Medications and Supplies: An unlocked treatment cart was observed unattended in a hallway and contained a resident's silver sulfa cream, wound supplies, scissors, and wound cleaning liquid. An LPN stated carts should be locked at all times and said she forgot to lock the cart while stepping away to get supplies. The DON stated all carts should be locked when not in use, and the facility policy required the medication cart to be completely locked or otherwise secured.
A CNA provided a list containing names and medical appointment details of ten residents to a resident, intending for it to be given to the volunteer Ombudsman. The list included sensitive health information such as upcoming or missed appointments with various specialists. The resident who received the list was cognitively intact and later gave it to the DON. The CNA admitted to breaching confidentiality, and facility records confirmed prior training on privacy policies.
Staff failed to use required PPE, including gowns, and did not consistently perform hand hygiene while providing high-contact care to a resident on enhanced barrier precautions for a wound and Foley catheter. Despite clear care plans and facility policies, multiple staff members provided wound care, incontinence care, and assistance with dressing using only gloves, and one LVN did not perform hand hygiene between glove changes. Staff interviews revealed awareness of the requirements but cited forgetfulness and lack of PPE supplies as reasons for non-compliance.
A resident with dementia and physical impairments reported missing money to a housekeeper, who failed to notify the administrator or initiate a timely report of the alleged misappropriation. The incident was not reported to facility leadership or authorities as required by policy, resulting in a delay in investigation and notification.
Three residents experienced deficiencies in their living environment, including a restroom that was not cleaned daily and prolonged lack of hot water in restrooms. One resident's restroom contained standing feces and a strong odor, while multiple residents had to use alternative hygiene methods due to the absence of hot water. Staff interviews and facility logs confirmed that these issues persisted for an extended period and were not consistently reported or addressed according to facility policy.
Residents report that their requests and recommendations during council meetings are not being addressed, with the administration unresponsive and the grievance process ineffective. Complaints include long wait times for care, staff using personal phones during care, and selective snack distribution. Night shift staff are described as loud and unprofessional, with cultural differences cited as a factor. An incident involved an aide entering a shower room during a resident's shower, leaving the door open. Food menu variety is also a concern.
The facility failed to assess and obtain informed consent for bed rail use for two residents with dementia and fall risks. Both residents were observed using bed rails without documented assessments or consent forms. Interviews with staff and visitors revealed a lack of adherence to the facility's policy, which requires assessment, consent, and care planning before installing bed rails.
A resident with severe cognitive impairment received expired insulin due to improper labeling and storage practices at the facility. The LVN administered insulin pens that were not dated upon opening, and the pens were stored with office supplies, leading to confusion about their usability. The facility's policy required insulin to be dated and stored separately, but these procedures were not followed, resulting in the administration of potentially ineffective medication.
A facility experienced a 7% medication error rate due to two incidents: a CMA administered Methocarbamol to the wrong resident, and an LVN gave expired Lantus insulin to a resident. The errors were identified during medication pass observations, revealing non-compliance with facility policies on medication labeling and dating.
A facility failed to properly store and label insulin, leading to the administration of expired insulin to a resident with diabetes. Insulin pens were found undated and stored with office supplies, contrary to policy. The LVN was unaware of the opening dates, and the ADON and DON acknowledged the lapse in medication management practices.
A resident with Alzheimer's Disease experienced a delay in receiving medical treatment due to the facility's failure to promptly follow up on x-ray results. The resident complained of knee pain, and an x-ray revealed a fracture, but the results were not communicated in a timely manner, leading to an 8-hour delay in sending the resident to the hospital. Staff interviews highlighted a lack of a written policy and inconsistent follow-up on x-ray orders.
A resident with significant medical needs, including a tracheostomy and anoxic brain damage, was found without access to a call button, which was placed on a dresser instead of within reach. Staff interviews confirmed the oversight, acknowledging the responsibility to ensure call lights are accessible to all residents, as per facility policy on resident rights.
A resident with a history of brain injury and a previous order for a fall mat experienced a fall resulting in a skin tear due to the facility's failure to provide the necessary care devices. Multiple staff members were aware of the missing fall mat but did not ensure it was in place, leading to the resident's injury.
A resident with a history of traumatic subdural hemorrhage and brain injury fell and sustained a skin tear due to the facility's failure to ensure a fall mat was in place as ordered. The CNA was aware of the missing fall mat but did not take action, leading to the resident's injury. Interviews with staff revealed a lack of adherence to the resident's care plan and MD orders.
A resident with severe cognitive impairment and a history of falls sustained injuries after falling out of bed due to the facility's failure to implement fall precautions and report the incident promptly. The fall mat was not in place, and staff did not follow the care plan and MD orders, leading to neglect.
A resident with severe cognitive impairment and multiple medical conditions fell out of bed and sustained injuries. The facility failed to report the incident to the state in a timely manner and did not document an investigation as required by their policy.
Failure to Report Resident Disclosure of Outside Weight Loss Medication
Penalty
Summary
The deficiency involves staff failing to report a resident’s disclosure that he was receiving a weight loss medication from his family that was not provided or ordered by the facility. The resident was an older adult male with acute respiratory failure as his primary diagnosis and additional conditions including anxiety disorder, acute on chronic systolic congestive heart failure, acute pulmonary edema, type 2 diabetes mellitus, and obesity. His medical record showed no physician order for a weight loss medication and no care plan addressing weight loss medication or self-administration of medications; his care plan specified that medications were to be given as ordered by the physician. On one occasion, a nurse (LVN A) documented entering the resident’s room and witnessing a family member handing the resident a syringe, then observing the resident self-inject into his lower abdomen. The family member stated at that time that the injection was for anxiety and claimed that everyone in the facility knew about it. LVN A requested to see the syringe, but the family member refused and later stated it was just water used as a placebo. The nurse documented the event and notified the DON and physician. Another nurse (LVN D) reported that the same family member told staff at the nurse’s station that the medication was for weight loss, and LVN D stated she did not hear the family member say it was for anxiety. A CNA (CNA B) later reported that the resident had told her his family member was giving him medication for weight loss. CNA B stated she never actually saw the family member give the medication and had not heard from other staff that the resident was taking weight loss medication, and she did not report the resident’s statement to her supervisor because she did not think it needed to be reported at the time. Other licensed nursing staff (RN C and LVN D) stated they had not been told by the resident that he was taking medications not provided by the facility and indicated they would have reported such information to the DON, ADM, and physician if they had known. The facility’s abuse/neglect policy states that each individual is responsible for recognizing and reporting situations that may constitute abuse or neglect, and that any person with reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state, and/or adult protective services. Despite this policy and the expectation from the DON and ADM that staff report knowledge of residents receiving outside medications, CNA B did not report the resident’s disclosure about weight loss medication, leading to the cited deficiency.
Failure to Disinfect Reusable BP Wrist Cuffs Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an infection prevention and control program by not sanitizing reusable blood pressure (BP) wrist cuffs between residents. On the identified date, a medical assistant (MA) used two wrist blood pressure monitors (BPM #1 and BPM #2) to obtain BP readings for eight residents without disinfecting the wrist cuffs between uses. The facility’s own infection control plan required that reusable equipment be appropriately cleaned, disinfected, or reprocessed, and staff interviews confirmed that BP cuffs were expected to be sanitized between residents to prevent cross contamination. Surveyors observed the MA attempting to obtain a BP reading on one male resident using BPM #1, then immediately using the same device on another resident’s wrist without sanitizing the cuff. The MA then proceeded through a series of residents, using BPM #1 and BPM #2 on their wrists and repeatedly failing to sanitize the cuffs after each BP measurement. After each encounter, the MA washed and dried her hands before exiting the room, but no cleaning of the wrist cuffs was performed between residents. The residents involved had multiple medical diagnoses, including Parkinson’s disease, tremors, traumatic brain injury history, type 2 diabetes mellitus, chronic kidney disease stage 4, and essential (primary) hypertension. Their cognitive status ranged from no cognitive impairment (BIMS scores 14–15), to moderate impairment (BIMS 9), to severe impairment (BIMS 1), and some were unable to complete interviews. During an interview, the MA stated that the cuffs were sanitized between each resident only when residents had COVID, and showed the surveyor the wipes used for cleaning equipment. Other nursing staff, including LVNs and the DON, stated that BP cuffs must be sanitized between each resident to avoid cross contamination, underscoring that the observed practice did not follow facility policy or expected infection control procedures. This failure could place residents at risk of infection.
Insufficient RN Weekend Coverage
Penalty
Summary
The facility failed to ensure a Registered Nurse was on duty in the facility for a minimum of eight consecutive hours a day, seven days a week, on 6 of 26 weekend days reviewed for RN coverage: 11/01/2025, 11/02/2025, 11/15/2025, 11/16/2025, 11/29/2025, and 11/30/2025. Review of an undated Excel file covering RN time stamp hours for weekend dates of the first fiscal quarter of 2026 showed insufficient RN coverage on those dates. During interview, the DON stated she was responsible for RN weekend schedules and said RNs were scheduled to work 6:00 PM to 6:00 AM on weekends, with a break from 6:00 AM to 6:00 PM before returning for the next 6:00 PM to 6:00 AM shift, which provided 6 hours of coverage in the morning and 6 hours in the evening. The DON said she had thought the facility only needed at least 8 hours of coverage during weekend days, not 8 consecutive hours. The ADM stated he understood the RN weekend day schedule as 6:00 AM to 6:00 PM because that was the weekday schedule, and the facility did not have a policy regarding nurse staffing.
Unlocked Treatment Cart with Resident Medications and Supplies
Penalty
Summary
The facility failed to provide safe and secured storage of drugs and biologicals by leaving a treatment cart unlocked while it was not in use. During observation, the treatment cart in hall 400 was found unlocked and contained Resident #1's silver sulfa cream, wound supplies, 2 pairs of scissors, and 2 bottles of wound cleaning liquid. The cart remained unlocked and unattended for 5 minutes. During interview, the treatment nurse stated that medication carts and treatment carts should be locked at all times because of the risk of injury to residents and HIPAA violation. She stated that a resident could have accessed the wound cleaning liquid and sustained chemical injuries, or used the scissors and sustained physical injuries. She also stated she forgot to lock the wound cart when she walked back to the medication room to get supplies to refill it. The DON stated that all carts should be locked at all times when not in use and that nurses were trained to lock all carts even if stepping away briefly. Review of the facility policy, Medication Administration Procedures, dated 10/25/2027, stated that the medication cart must be completely locked, or otherwise secured.
Unauthorized Disclosure of Resident Medical Information
Penalty
Summary
A certified nursing assistant (CNA) assigned as the facility's transport person provided a list containing the names and medical appointment details of ten residents to another resident. The list included specific information about each resident's upcoming or missed medical appointments, such as MRI, orthopedic, podiatry, pain management, pulmonary, urology, nephrology, and dermatology visits. The CNA gave this list to a resident with the intention that it be delivered to the volunteer Ombudsman. The resident who received the list was cognitively intact, as indicated by a BIMS score of 15, and later presented the list to the Director of Nursing (DON), expressing frustration over the CNA's suspension. The CNA admitted to providing the list and acknowledged that this action breached residents' confidentiality. The volunteer Ombudsman confirmed that he did not receive the list. Facility records showed that the CNA had previously completed training on confidentiality and had signed a privacy and non-disclosure agreement. The facility's policy states that residents have the right to personal privacy and confidentiality of their personal and medical records. The incident was identified through interviews and record reviews, and it involved the unauthorized disclosure of protected health information to an unauthorized individual.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for a resident on enhanced barrier precautions due to a wound and an indwelling Foley catheter. On the observed date, multiple staff members, including a CNA and two LVNs, did not use the required personal protective equipment (PPE) such as gowns while providing high-contact care activities like wound care, dressing, and incontinence care. Specifically, staff entered the resident's room, which was marked for enhanced barrier precautions, and performed care activities wearing only gloves but no gowns, despite facility policy and physician orders requiring both gloves and gowns for such interactions. During wound care and incontinence care, one LVN failed to perform hand hygiene between glove changes when moving from dirty to clean tasks. The staff involved acknowledged during interviews that they were aware of the requirements for PPE and hand hygiene but cited reasons such as forgetting or lack of PPE supplies immediately available outside the resident's room. The absence of a PPE cart outside the room was noted as a contributing factor for non-compliance by one CNA. The resident involved was a female with a history of hypertension, end stage renal disease, and cerebral vascular accident, and was assessed as moderately cognitively impaired. Her care plan and physician orders specifically required enhanced barrier precautions, including the use of gloves and gowns for high-contact activities. Facility policy also emphasized the importance of hand hygiene and proper PPE use to prevent the transmission of infection.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an alleged violation involving misappropriation of a resident's property within the required 24-hour timeframe to the administrator and appropriate authorities. A female resident with vascular dementia, hemiplegia, and other significant medical conditions reported that $90 was stolen from her bedside table over the course of several days. The resident, who was her own responsible party and had a BIMS score indicating intact cognition, did not initially report the missing money to facility leadership but mentioned it to a housekeeper. The housekeeper, upon being informed by the resident about the missing money, did not report the incident to the administrator, believing the resident had already done so. The housekeeper assisted the resident in securing some remaining money by placing it in an envelope and hiding it in a book in the resident's drawer, but did not consider offering a lock box or formally reporting the theft. Interviews with other staff, including CNAs and the business office, revealed that they were unaware of the missing money and had not received any reports regarding theft or misappropriation. The business office confirmed the resident had made several cash withdrawals but had not been informed of any missing funds. Both the administrator and DON stated they were not aware of the incident until the day of the survey and emphasized that all staff are expected to report such incidents immediately, as per facility policy and recent in-service training. Facility policy requires all allegations of abuse, neglect, exploitation, or misappropriation of resident property to be reported to the administrator, who must then notify the appropriate authorities within specified timeframes. The failure of the housekeeper to report the resident's allegation of missing money resulted in a delay in investigation and notification, contrary to facility policy and regulatory requirements. This lapse was identified during the survey through interviews and record reviews, which confirmed that the incident was not reported until the surveyor's inquiry.
Failure to Maintain Clean Restrooms and Hot Water Access for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents by not ensuring daily cleaning of a resident's restroom and by not providing hot water in the restrooms for multiple residents. One resident's restroom was observed to have standing feces in the toilet and a strong foul odor that extended into the resident's room, with the restroom door closed. The resident reported that housekeeping cleaned her room but not the restroom, and staff interviews confirmed that the restroom was not cleaned because it was believed the resident did not use it. The toilet was also found to be clogged, and this issue was not reported in the maintenance log as required by facility policy. Multiple residents, including those with chronic conditions such as COPD and those requiring assistance with activities of daily living, did not have access to hot water in their restrooms for an extended period. Staff and residents reported that the lack of hot water had persisted for more than a week, and water temperature logs confirmed repeated and prolonged outages of hot water on several halls. Residents had to use alternative means for personal hygiene, such as antibacterial wipes or being taken to other halls for showers, and expressed dissatisfaction and discomfort with these arrangements. Facility records showed inconsistent documentation of water temperature checks, with significant gaps in the log and repeated notations of no hot water available. Maintenance staff attributed the hot water outages to recurring slab leaks and aging infrastructure, and invoices confirmed ongoing plumbing repairs. Despite these issues, the facility's own policies required daily checks and prompt repair of hot water systems, as well as regular cleaning and maintenance of resident restrooms, which were not consistently followed.
Resident Council Concerns and Staff Inaction
Penalty
Summary
Residents have reported that their requests and recommendations made during resident council meetings are not being addressed by the facility staff. The administration has been unresponsive, with residents being told that their issues have been overlooked and need to be restarted from the beginning. The grievance process, which should be initiated with the social worker, is reportedly not being followed, with the administrator acting as the grievance representative but failing to respond to residents' concerns. Additionally, there are complaints about long wait times for care, staff engaging in personal conversations and using personal cell phones during care provision, and selective distribution of snacks, particularly during the 6 PM to 6 AM shift. Residents feel that their rights are being dismissed, and there is a lack of respect for their choices and rights, especially during the night shift. There are also issues with the night shift staff being loud and unprofessional, with cultural differences being cited as a contributing factor. The social worker has been inconsistent in following through with grievances, with some cases remaining unresolved for months. Residents have expressed concerns about potential retaliation from management for filing grievances. An incident was reported where an aide entered a shower room to converse with another aide while a resident was undressed, leaving the door open. Additionally, there are complaints about the lack of variety in the food menu, with residents feeling that the state should have more control over kitchen operations. The facility's grievance process appears to be ineffective, with ongoing issues not being resolved in a timely manner.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of bed rails and enabler bars for two residents, identified as Residents #3 and #63. Both residents were observed using bed rails without documented assessments or consent forms in their medical records. Resident #3, who has a history of dementia, muscle weakness, and falls, was found asleep in bed with raised half bedrails on multiple occasions. Despite the resident's cognitive impairments and reliance on a wheelchair for mobility, there was no documentation of an assessment for the safe use of bed rails or a signed consent form in the resident's care plan. Similarly, Resident #63, who also suffers from severe dementia and repeated falls, was observed with a raised half bed rail. The resident's care plan did not include the use of bed rails as an intervention, and there was no evidence of an assessment or consent form in the medical records. Interviews with the resident's visitor and facility staff revealed that the resident felt more secure with the bed rails, but neither the resident nor the visitor recalled any assessment or consent process being completed. Interviews with facility staff, including the Maintenance Manager, CNA, ADON, DON, and ADM, highlighted a lack of adherence to the facility's policy on bed rail use. The policy requires an assessment for risk of entrapment, informed consent, and proper care planning before installing bed rails. Despite these requirements, the facility did not provide adequate documentation or follow the necessary procedures for Residents #3 and #63, leading to the deficiency identified in the report.
Expired Insulin Administered Due to Improper Labeling and Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, specifically in the administration of insulin. A Licensed Vocational Nurse (LVN) administered expired insulin to a resident with type 2 diabetes mellitus and high blood pressure. The insulin pens used were not labeled with the date they were opened, which is a requirement to ensure the medication's potency and effectiveness. The LVN was unaware of when the insulin pens were opened and assumed they were still effective because the resident was newly admitted. The resident in question was a female with severe cognitive impairment, as indicated by her BIMS score, and had long-term and short-term memory problems. During a medication pass observation, it was noted that the insulin pens were stored improperly with office supplies, and two of the pens lacked opening dates. The LVN believed the insulin was still within the usable time frame, but this assumption was incorrect due to the lack of proper labeling and storage. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that the facility's policy required insulin to be dated upon opening and stored separately from non-medical items. The ADON and DON were responsible for conducting medication cart audits, but the oversight in labeling and storage was missed. The facility's policy also specified the expiration time frames for different types of insulin, which were not adhered to in this case.
Medication Administration Errors Lead to 7% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a 7 percent error rate. This was due to two specific incidents involving medication administration errors. In the first incident, a Certified Medication Aide (CMA) administered Methocarbamol 500 MG intended for one resident to another resident. The CMA admitted to being nervous and mistakenly took the medication belonging to the roommate of the intended recipient. In the second incident, a Licensed Vocational Nurse (LVN) administered expired Lantus insulin to a resident. The LVN was unaware of the expiration date and believed the insulin was still effective because the resident had been recently admitted. The errors were identified during observations of medication passes and interviews with the involved staff. The facility's policies required medications to be dated when opened, and the manufacturer's guidelines for insulin indicated it should be used within 28 days of opening. However, the LVN did not adhere to these guidelines, leading to the administration of expired insulin. Interviews with the Director of Nursing (DON) and the administrator revealed expectations for staff to follow the seven rights of medication administration and ensure medications were properly labeled and dated. Despite these policies, the errors occurred, contributing to the facility's medication error rate exceeding the acceptable threshold.
Improper Storage and Labeling of Insulin in Medication Cart
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, specifically insulin, in accordance with professional principles. During an observation, it was found that expired insulin was not removed from the nurse medication cart in the secure unit. Additionally, insulin pens were stored alongside office stationery items such as pens, markers, paper clips, and rubber bands, which is against the facility's policy for medication storage. A resident with type 2 diabetes mellitus and severe cognitive impairment was involved in this incident. The resident had active orders for both long-acting and short-acting insulin. During a medication pass, it was observed that the insulin pens were undated, and one of the pens was expired. The LVN administering the medication was unaware of when the insulin pens were opened and proceeded to administer insulin from an expired pen to the resident. Interviews with the LVN, ADON, and DON revealed a lack of adherence to medication storage policies. The LVN admitted to not knowing who placed the stationery items with the insulin and was unaware of the opening dates of the insulin pens. The ADON and DON acknowledged that insulins should be dated and stored separately from other items to prevent contamination. Despite regular audits, the issue was not identified until the survey, indicating a lapse in the facility's medication management practices.
Delayed X-ray Results Lead to Hospitalization
Penalty
Summary
The facility failed to provide timely radiology services for a resident, leading to a delay in diagnosis and treatment. The resident, who had Alzheimer's Disease and severe cognitive impairment, complained of right knee pain, which was assessed as swollen and tender. An x-ray was ordered, but the results indicating a fracture were not promptly communicated to the facility, resulting in a delay in sending the resident to the hospital for further evaluation and treatment. The deficiency was identified when the Director of Nursing (DON) reviewed the nursing documentation and discovered the delay in receiving and acting upon the x-ray results. The x-ray company did not follow their protocol of faxing or calling the facility with critical results, and the facility staff did not access the results through the available portal. This communication breakdown led to an 8-hour delay in addressing the resident's fracture. Interviews with facility staff revealed a lack of a written policy on x-ray services and inconsistent follow-up on ordered x-rays. Staff were in-serviced on the importance of timely follow-up on stat x-rays and the need to notify the physician if results were delayed. The facility's failure to ensure timely communication and follow-up on diagnostic services resulted in delayed medical treatment and hospitalization for the resident.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the facility did not place the call button within reach of a resident who was dependent on staff for assistance. The resident, a male with anoxic brain damage, tracheostomy, and other medical conditions, was observed in bed with the call button placed on a dresser, making it inaccessible. This oversight was noted during an observation and attempted interview, where the resident was unable to respond to questions about the call button. Interviews with staff, including an LVN, the DON, the Administrator, a CNA, and the Corporate Compliance Nurse, revealed that it was the responsibility of all staff to ensure call lights were within reach of residents. Despite the resident's inability to use the call button frequently, it was acknowledged that it should be accessible to him. The CNA admitted to placing the call pad on the dresser and forgetting to return it to the bed, where the resident could access it. The facility's policy on resident rights emphasized the importance of providing reasonable accommodation for resident needs and preferences, which was not adhered to in this instance.
Failure to Prevent Resident Fall Due to Missing Fall Mat
Penalty
Summary
The facility failed to ensure that Resident #1 was free from neglect when they did not provide the necessary care devices to prevent injury from a fall. Resident #1, who had a history of traumatic subdural hemorrhage with brain injury and a previous order for a fall mat, experienced a fall resulting in a skin tear. The CNA was aware that the fall mat was missing but did not notify the head nurse, leading to the resident's fall and subsequent injury. The deficiency was further highlighted by the fact that multiple staff members, including the DON, LVN, and RN, were aware of the missing fall mat but failed to ensure it was in place. The DON admitted that the fall mat should have been in place and that the staff did not review MD orders, care plans, and assessments to ensure the resident's safety. The incident occurred over several shifts, indicating a systemic failure to follow through on care protocols. Interviews with various staff members revealed a lack of familiarity with Resident #1's care requirements and a failure to review and implement MD orders. The facility's policy on abuse and neglect was not followed, as the staff did not provide the necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. This neglect led to Resident #1's fall and injury, demonstrating a significant lapse in the facility's duty of care.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not provide the necessary care devices to prevent injury from a fall for a resident with a history of traumatic subdural hemorrhage and brain injury. The resident had a previous order for a fall mat, which was not in place at the time of the incident. As a result, the resident experienced convulsions/seizures, fell, and sustained a skin tear on the forehead. The resident's medical history included a traumatic subdural hemorrhage with loss of consciousness, conversion disorder with seizures, and chronic respiratory failure. The resident was nonverbal and had severely impaired cognition, as indicated by a BIMS score of 0. Despite these conditions, the facility staff failed to ensure that the fall mat was in place, which was a critical intervention to prevent falls and related injuries. The CNA on duty was aware that the fall mat was missing but did not take action to rectify the situation, leading to the resident's fall and subsequent injury. Interviews with facility staff, including the CNA, DON, and other nursing staff, revealed that there was a lack of adherence to the resident's care plan and MD orders. The DON acknowledged that the fall prevention precautions were not followed, and the CNA admitted that the fall mat was not applied next to the resident's bed. This failure to implement and monitor fall prevention devices as ordered contributed directly to the resident's fall and injury. The facility's policy on fall prevention strategies was not effectively executed, resulting in the identified deficiency.
Failure to Implement Fall Precautions and Report Neglect
Penalty
Summary
The facility failed to implement their written policies and procedures regarding allegations of neglect for a resident who fell out of bed and sustained injuries to his forehead. The resident, who had a history of traumatic subdural hemorrhage, neuromuscular dysfunction, and chronic respiratory failure, was found to have severely impaired cognition and was nonverbal. Despite having a care plan that included fall precautions such as a floor mat next to the bed, these measures were not followed, leading to the resident's fall and subsequent injuries. On the day of the incident, the resident's fall mat was not in place, and the nursing staff did not ensure its presence during their shifts. The resident fell out of bed, resulting in skin tears on his forehead. The incident was not reported immediately, and the fall mat was not placed back after the fall. Interviews with the staff revealed that they were aware of the missing fall mat but failed to take corrective action. The Director of Nursing (DON) confirmed that the fall mat was not in place and acknowledged that the staff did not follow the care plan and MD orders. The facility's policy on abuse and neglect requires immediate evaluation and reporting of such incidents, but this protocol was not followed. The staff's failure to implement the fall precautions and report the incident promptly led to the resident's injuries. The DON and other staff members admitted that neglect occurred due to the failure to provide the necessary care as outlined in the resident's care plan and MD orders.
Failure to Report and Investigate Resident Fall
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not follow its policy on reporting neglect when a resident fell out of bed and sustained injuries to his forehead. The incident was not reported to the state in a timely manner, and there was no documentation of an investigation into the fall and injuries as required by the facility's policy. The resident involved was a male with a history of traumatic subdural hemorrhage, conversion disorder with seizures, chronic respiratory failure with hypoxia, and dysphagia. He was severely cognitively impaired and nonverbal, with a feeding tube and a stage 4 wound. The resident fell out of bed and sustained two injuries to his forehead. Despite the fall and injuries being reported to the Director of Nursing (DON) and the Administrator, the incident was not immediately reported to the state, and no investigation was documented. Interviews with staff revealed that the fall was reported to the charge nurse and the DON, and the resident was assessed and treated for his injuries. However, the Administrator did not initially report the incident to the state, as he did not consider the injuries life-threatening. The facility's policy required immediate reporting and documentation of the investigation, which was not followed in this case.
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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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Nursing homes near Lake Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fort Worth Wellness & Rehabilitation | 3.1 mi | ★★★★★ | 0 | 0 |
| White Settlement Nursing Center | 3.8 mi | ★★★★★ | 6 | 0 |
| River Oaks Health And Rehabilitation Center | 4.1 mi | ★★★★★ | 16 | 2 |
| Marine Creek Nursing And Rehabilitation | 4.5 mi | ★★★★★ | 18 | 0 |
| Willow Ridge Wellness & Rehabilitation | 4.9 mi | ★★★★★ | 3 | 1 |
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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.