Inspection Reports for Lakeside Nursing and Rehabilitation Center

The facility was found deficient in maintaining resident privacy during care, ensuring accurate Minimum Data Set (MDS) assessments for residents on antipsychotic medications, proper food storage and sanitation in the kitchen, and adherence to infection control practices during colostomy care.

The facility was found deficient in ensuring residents' call lights were within reach, timely administration of medications as ordered, and maintaining a safe, functional, and comfortable environment due to floor cracks in a resident's room. These deficiencies posed risks to resident safety, dignity, and therapeutic outcomes.

The facility was found deficient in multiple areas including failure to ensure call lights were within reach, failure to provide written notice for room changes, inadequate response to resident council grievances, lack of baseline care plans for new admissions, medication administration errors, improper medication storage, failure to follow puree diet recipes, unsafe room environment due to floor cracks, and ineffective pest control in the dining area.

The complaint involved allegations of abuse where CNAs took unauthorized photos and videos of residents in vulnerable states and shared them in a CNA chat group. The facility failed to report the abuse timely, and some staff failed to report the incidents at all. The noncompliance began on February 5, 2024, and ended on February 6, 2024, when the facility corrected the issues.

The facility failed to protect residents from abuse, including unauthorized photography and video recording of residents in vulnerable situations by CNAs, failure to report the incidents timely, and failure to have adequate policies and procedures to prevent abuse. The facility corrected the noncompliance before the survey began by terminating or suspending involved staff, providing in-service training to all staff, and completing psychiatric evaluations and assessments of affected residents.

The complaint investigation revealed that Resident #1's family member was denied medical records because they were not the responsible party (RP), power of attorney (POA), or guardian. The family member lacked written POA documentation, and the facility required such documentation before releasing medical files. The family member was informed by a family attorney that POA was not required because a family member signed the admission. The facility recognized the admission office failed to establish the RP and did not encourage seeking guardianship for the cognitively impaired resident.

The facility failed to ensure that Resident #1 had a designated representative with authority to make decisions on his behalf, resulting in denial of medical records to the family member who was not recognized as the responsible party or guardian. The admission process failed to establish a responsible party for the cognitively impaired resident, and the facility did not encourage the family to seek guardianship.

The facility failed to develop and implement an accurate, comprehensive person-centered care plan for one resident, failed to remove expired food products in the kitchen and nutrition room, failed to provide a neutral and fair arbitration process with a convenient venue for residents, and failed to maintain proper infection control practices by not sanitizing blood pressure cuffs between residents.

The complaint investigation found that the facility did not notify Resident #5's physician of the redness on the resident's left arm on 12/27/22. Interviews with Wound Care LVN C, NP E, the Director of Nursing, and Wound Care Physician F confirmed the lack of notification. The facility policy requires prompt communication of all changes in resident condition to the physician.

The facility failed to notify Resident #5's physician about the redness on the resident's left arm, resulting in a delay in medical intervention. Documentation showed no Change of Condition form or progress note indicating physician notification. Interviews confirmed staff did not notify the physician as required by facility policy.

The complaint investigation focused on Resident #1's lack of access to vision services. The social worker and nursing staff failed to schedule and follow up on optometry appointments. Resident #1 and her responsible party reported concerns about the lack of follow-up and eye pain. The facility also lacked a policy for vision services. The governing body failed to appoint a licensed administrator, which could affect overall facility management.

The facility failed to schedule an optometry appointment for Resident #1 since August 2022 despite multiple requests and documented needs. Interviews revealed lack of follow-up by social worker and nursing staff, absence of a vision services policy, and failure to ensure the resident received necessary eye care. Additionally, the facility did not appoint a properly licensed administrator as required by state regulations.

The facility failed to ensure the governing body appointed a state-licensed administrator responsible for management. The Operations Manager was acting as administrator but was not licensed in Texas and the licensed preceptor was present only about once a week, not meeting statutory requirements.