Inspection Reports for
Lantern Park Specialty Care

The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medication changes, incomplete and untimely resident assessments, inadequate assistance with activities of daily living, unsafe respiratory care practices, lack of trauma-informed care, and delayed response to call lights.

Complaint #129505-C resulted in a deficiency related to failure to obtain informed consent for psychotropic medication changes.

The facility was found to have multiple deficiencies including failure to obtain informed consent for psychotropic medication changes, incomplete comprehensive assessments after significant changes, failure to complete quarterly assessments timely, inadequate ADL care for dependent residents, respiratory care issues, trauma-informed care deficiencies, and insufficient nursing staff to respond to call lights timely.

The complaint investigation found substantiated issues with bathing frequency for Residents #13 and #61. The Administrator confirmed that all residents should receive showers twice a week.

The facility failed to provide at least two baths per week for 2 of 3 residents reviewed. Interviews and documentation revealed inconsistent showering schedules and delays in providing showers as required by care plans.

Complaint #124069-C was substantiated regarding the allegation of physical abuse of Resident #2. The facility failed to thoroughly investigate the allegation and failed to interview all relevant staff. The facility notified regional clinical staff, police, and the Department of Inspections, Appeals, and Licensing (DIAL).

The facility failed to thoroughly investigate an allegation of physical abuse for one resident and failed to ensure residents were free from significant medication errors for six of ten residents reviewed. Additionally, the facility failed to obtain physician orders for supplemental oxygen and failed to administer medications as ordered.

The complaint investigation was triggered by an allegation from Resident #2 that she was hit in the head during the overnight hours of 10/03/24. The facility collected statements from residents and staff but failed to interview staff who worked the night of the incident. The allegation was reported to regional clinical staff, police, and the Department of Inspections, Appeals, and Licensing.

The facility failed to thoroughly investigate an allegation of physical abuse for one resident and failed to obtain physician orders for supplemental oxygen and to administer medications as ordered for multiple residents. The facility reported a census of 84 residents.

Complaints #123604-C and #123608-C were substantiated following the investigation conducted from September 23 to September 26, 2024.

The facility failed to provide baths for 1 out of 3 residents reviewed (Resident #1), who required assistance with activities of daily living. Documentation showed Resident #1 only received one bath in August 2024 and no documentation for September. Staff interviews confirmed that residents should receive baths twice weekly, but this was not consistently done.

The facility failed to provide baths as required for 1 of 3 residents reviewed, specifically Resident #1, who did not receive the scheduled baths twice weekly. Documentation showed only one bath in August and none in September, despite care plans and staff interviews confirming the expectation of twice-weekly baths.

The investigation was triggered by complaints #122999-C, #123362-C, #123424-C and facility reported incidents #123422-I and #123486-I. Facility reported incident #123486-I was substantiated.

The facility failed to update residents' care plans to reflect current levels of functioning, failed to transfer a resident requiring a mechanical lift safely, and failed to provide appropriate supervision during ambulation resulting in injury. Specific deficiencies were noted in care planning, transfer assistance, and accident prevention.

The facility failed to update care plans to reflect residents' current functioning, failed to ensure safe transfers using mechanical lifts properly, and failed to provide adequate supervision during ambulation resulting in a resident fall and injury.

The facility failed to treat residents with respect and dignity, failed to ensure residents were informed about medication changes, did not complete updated PASRR evaluations for residents with new diagnoses, and failed to submit complete payroll data for agency staff. Several residents reported delays in call light responses and rude staff behavior.

Complaints #122179-C and #122180-C were substantiated, involving resident rights violations and staff mistreatment. Complaints #122367-C and #122374-C were not substantiated.

The facility was found to have deficiencies related to resident rights, including failure to treat residents with respect and dignity, inadequate response to call lights, and failure to inform residents about medication changes and treatment decisions. Complaints #122179-C and #122180-C were substantiated, while #122367-C and #122374-C were not substantiated.

The investigation was initiated based on complaints of staff mistreatment and poor call light response. Staff A was terminated for inappropriate comments to Resident #78. Two CNAs received disciplinary action for rude behavior toward Resident #4. Residents #13 and #86 reported delays in call light responses. The complaints were substantiated with corrective actions including staff education and re-training.

The facility failed to treat residents with respect and dignity, with multiple incidents of staff being rude or inappropriate to residents. Additionally, residents reported delays in answering call lights, sometimes up to two hours, causing distress and unmet care needs.

Complaint #120607-C was substantiated. Facility Reported Incidents #120020-I and #120367-I were substantiated, with #120367-I substantiated without additional deficiencies.

The facility failed to complete an accurate assessment and provide intervention after a fall for one resident, and failed to provide appropriate supervision to ensure safety for three residents. Deficiencies were substantiated related to quality of care and free of accident hazards.

The facility failed to complete an accurate assessment and provide appropriate intervention after a resident fall, resulting in a nondisplaced fracture. Additionally, the facility failed to provide adequate supervision and safe lifting practices, contributing to the resident's fall and injury.

The investigation was triggered by complaints #115592-C (not substantiated), #117109-C, #118198-C, #118862-C, and #119464-C (all substantiated). The facility failed to meet requirements related to reporting alleged violations, investigating medication errors, and providing adequate care to residents.

The facility failed to properly report and investigate alleged drug diversion and medication errors, maintain accurate medication records, and provide adequate assistance with activities of daily living and wound care for residents. Multiple deficiencies were identified related to medication administration, investigation of alleged violations, ADL care, treatment of pressure ulcers, bowel/bladder care, pharmacy services, and food sanitation.

The facility failed to timely report suspected drug diversion, adequately investigate alleged violations, provide sufficient bathing assistance, carry out wound treatment orders, ensure timely catheter care, safeguard PRN medications, and maintain sanitary food service conditions.

The facility had multiple deficiencies including failure to provide advance directive information, privacy breaches, inadequate notification of transfers, failure to maintain residents' functional abilities, insufficient activities for residents with dementia, pressure ulcer care deficiencies resulting in immediate jeopardy, accident hazard management failures, medication errors, incomplete facility assessment, and infection prevention and control program deficiencies.

Investigation of Complaint #112337-C conducted from May 15, 2023 to May 18, 2023. The complaint involved issues related to advance directives, confidentiality of records, pressure ulcer care, medication errors, and infection control. The complaint was substantiated with multiple deficiencies found.

The facility was found deficient in multiple areas including failure to provide residents and their representatives with written information about advance directives, failure to maintain confidentiality of residents' medical records, inadequate activities to meet residents' needs, failure to prevent and treat pressure ulcers, medication errors, improper storage of drugs and biologicals, and failure to maintain an effective infection prevention and control program. Corrective actions and quality assurance plans were implemented to address these deficiencies.

The facility had multiple deficiencies including failure to notify healthcare providers and family of critical lab results, incomplete and inaccurate care plans, medication administration errors, inadequate shower/bathing care, failure to properly assess and document resident conditions, inadequate wound care and infection control, and insufficient supervision leading to resident falls and injuries.

The investigation involved complaints 110252-C, 110362-C, 110509-C, 110630-C, and 110909-C. Complaints 110362-C, 110509-C, 110630-C, and 110909-C were substantiated. Complaint 110252-C and facility incident 110513-I were not substantiated. Facility incident 110703-I was substantiated.

The facility was found to have multiple deficiencies related to notification of changes, care plan timing and revision, services provided meeting professional standards, ADL care for dependent residents, quality of care, treatment and services to prevent and heal pressure ulcers, and free of accident hazards/supervision/devices. Several residents were affected by these deficient practices, including issues with notification of urinary tract infections, pressure ulcers, medication administration, and fall risk management.

Complaints #107900-C, #108384-C, #108490-C, #109095-C, #109952-C and Facility Self-Reported Incident #109993-I were substantiated.

The facility was found to have substantiated complaints involving abuse, neglect, and failure to provide adequate care including bathing assistance and respiratory/tracheostomy care. Deficiencies were identified in reporting alleged violations, providing ADL care, and respiratory care, resulting in immediate jeopardy that was later removed after corrective actions.

Complaints #103616 and #103618 were substantiated. The investigation found that Staff K had a criminal and dependent adult abuse history that was not properly addressed before employment. The facility was instructed to follow background check policies and suspended Staff K pending DHS evaluation. Additionally, deficiencies in ADL care for dependent residents were documented.

The facility failed to employ or engage staff with adverse actions as required by regulations, specifically related to Staff K who had a history of dependent adult abuse and was not properly evaluated before employment. Additionally, the facility failed to provide necessary ADL care including incontinence and catheter care for dependent residents, resulting in inadequate personal hygiene and care.

The investigation of complaint #96362-C and facility-reported incident #96363-I did not result in facility deficiency. Other complaints (#97237-C, #98170-C, #97025-I, #98174-I, #98309-I) were related to the annual survey findings.

The facility was found deficient in multiple areas including failure to follow physician orders for catheter changes, unsafe storage of oxygen tanks, insufficient nursing staff response to call lights, and inadequate infection prevention and control practices. The facility reported a census of 71 residents during the survey.

Complaint #873331 was investigated during the recertification survey and was not substantiated.

The facility was found deficient in several areas including failure to provide quarterly statements for residents' personal funds, lack of signed physician orders for residents' code status, failure to submit required PASARR Level II screenings, incomplete care plans, and inadequate monitoring and documentation of residents' conditions and treatments.