Inspection Reports for
Lighthouse Healthcare Center

The facility had multiple deficiencies including failure to honor resident care preferences, delays in conservatorship referrals, lack of informed consent for psychotropic medications, inaccurate resident assessments, incomplete care plans, poor hygiene and grooming, unsafe environmental conditions, medication errors, infection control lapses, and nonfunctional call systems.

The facility failed to ensure that nursing staff correctly interpreted and followed physician orders for changing a resident's urinary catheter drainage bag and did not follow facility policy for replacing humidifier bottles, placing residents at risk for infection and illness.

The facility failed to ensure one resident was offered and provided showers and baths as required, failed to notify the Primary Care Provider of the resident's refusals of showers/baths and wound care treatment, and failed to document weekly skin checks timely. These failures posed risks of skin irritation, infections, worsening skin conditions, and inaccurate medical records.

The complaint investigation revealed that Resident 1 was seriously injured and later died after the transportation van was double parked in the street and hit by a speeding vehicle. The facility failed to train staff on transportation safety, did not have a designated loading area, and did not follow policies to prevent accidents. Multiple staff interviews confirmed lack of training and unsafe practices.

The facility failed to ensure safe transportation for Resident 1, who was injured and later died after the medical transportation van was double parked and struck by another vehicle. The facility did not provide staff training on transportation safety, lacked a designated loading area, and failed to follow its policies on accident prevention and safety reporting.

The complaint investigation substantiated that Resident 2 physically abused Resident 1 by hitting him with a wet floor sign cone on 10/5/2024, causing a bruise and cut. The facility's failure to prevent this abuse was linked to unattended wet floor sign cones in the residents' rooms.

The facility failed to protect Resident 1 from physical abuse by Resident 2, resulting in a bruise and cut on Resident 1's right elbow. The facility also failed to ensure the environment was free from accident hazards by leaving wet floor sign cones unattended in residents' rooms, which contributed to the incident.

The complaint investigation found that Resident 1 was not informed about the lack of secondary coverage and was not assisted in applying for it. Interviews with the Administrator, Resident 1, Business Office Manager, and Director of Nursing confirmed these failures. Resident 1 was charged for stays after her medical coverage ended.

The facility staff failed to inform Resident 1 that she did not have secondary coverage during her stay and did not assist her in applying for secondary coverage. This resulted in Resident 1 living at the facility without knowledge of her coverage status and receiving a medical bill for uncovered services.

The complaint investigation found substantiated failures related to hypoglycemia management for Resident 1, including failure to notify the physician, administer ordered medication, assess the resident, and follow facility policies, resulting in risk of severe harm.

The facility failed to ensure Resident 1 received treatment and care according to professional standards by not notifying the physician of a low blood sugar level of 55 mg/dl, not administering Glucagon as ordered, not assessing the resident when nonresponsive, and not promptly notifying the physician. These failures placed Resident 1 at risk for severe medical complications, hospitalization, and death.

The facility was found deficient in multiple areas including failure to obtain informed consent for physical restraints, inaccurate resident assessments, incomplete care plans, improper medication storage, unsafe food handling, inadequate infection prevention education, and failure to provide effective communication aids for a deaf resident.

The facility failed to develop, implement, and update comprehensive care plans for 15 out of 25 residents, including failure to address psychotropic medication use, wandering behaviors, denture use, and physical restraints. This placed residents at risk for harm, including adverse medication effects, choking hazards, and unnecessary physical restraints. Care plans were also lacking for the use of bed rails and bed positioning against walls for multiple residents.

The investigation was complaint-driven, focusing on allegations that the facility failed to follow care plans for repositioning, did not properly monitor orthostatic blood pressures, and inadequately supervised a resident who subsequently fell and was injured.

The facility failed to provide two-staff assistance for repositioning a high fall-risk resident, did not accurately obtain orthostatic blood pressure readings for two residents, and allowed a high fall-risk resident to ambulate unsupervised, resulting in a fall with injury.

The facility failed to implement care plans requiring two staff assists for repositioning a resident, inaccurately obtained orthostatic blood pressure readings for two residents, and failed to adequately supervise a resident at high fall risk, resulting in an avoidable fall with injury.

The complaint investigation focused on failure to notify the physician of behavior changes and failure to timely report a resident-to-resident abuse incident. The abuse incident involved Resident 2 attacking Resident 1 in self-defense. The facility delayed reporting the incident to the State Survey Agency beyond the required 2-hour timeframe due to a failed fax transmission.

The facility failed to notify the physician of behavior changes for one resident, which had the potential to cause harm. Additionally, the facility did not report a resident-to-resident altercation to the State Survey Agency within the required 2-hour timeframe, potentially placing the resident at risk for elder abuse.

The complaint investigation found that the facility did not report a resident-to-resident altercation within the required two-hour timeframe. The altercation occurred on 2/27/2024 at 6:30 PM but was reported on 2/28/2024. The delay was acknowledged by staff including the Activities Assistant and Director of Social Services. The Director of Nursing confirmed all allegations of abuse must be reported within two hours.

The facility failed to report an incident of a resident-to-resident altercation between Resident 1 and Resident 2 within two hours of occurrence, potentially delaying necessary investigations and increasing risk of further altercations. Interviews and record reviews confirmed the altercation occurred on 2/27/2024 but was reported only on 2/28/2024.

The complaint investigation found that Registered Nurse 1 administered CPR to Resident 1 despite the resident's active DNR order on the POLST. The Director of Nursing confirmed this was a violation of the resident's rights and facility policy.

The facility failed to honor Resident 1's POLST DNR order, resulting in the resident receiving CPR despite the DNR status. This violated the resident's end-of-life care wishes and rights. Interviews with staff confirmed the error and the facility's policy requires adherence to DNR orders.

The facility failed to properly isolate a COVID-19 positive resident from exposed but negative residents, failed to ensure exposed residents wore masks, and staff did not consistently wear proper PPE or perform hand hygiene. The Administrator and Director of Nursing misinterpreted public health guidelines, resulting in potential increased risk of COVID-19 transmission within the facility.

The investigation was complaint-driven, focusing on infection control failures related to COVID-19 exposure and isolation practices. The complaint was substantiated with findings of improper resident cohorting, PPE use, and testing protocols.

The facility failed to isolate a COVID-19 positive resident from exposed but negative roommates, did not ensure exposed residents wore masks, and staff did not consistently use proper PPE or perform hand hygiene. The Administrator and Director of Nursing misinterpreted public health guidelines, placing residents and staff at risk.

The complaint investigation found that the facility did not involve the IDT in discharge planning for Resident 1 as required. The Responsible Party reported lack of assistance with the discharge process and no IDT meeting was documented or conducted despite scheduled meetings. The facility's Social Services Assistant and Director acknowledged the lack of IDT involvement and communication failures.

The facility failed to involve the IDT in discharge planning for Resident 1, resulting in incomplete or ineffective discharge planning. Interviews and record reviews confirmed no IDT meeting was held for discharge planning despite policy requirements, and the resident's Responsible Party was not assisted adequately with the discharge process.

The facility was found deficient in multiple areas including failure to maintain resident dignity, incomplete informed consent processes, inadequate privacy measures, improper use of restraints and alarms, inaccurate resident assessments, incomplete care plans, inadequate pain management, failure to perform gradual dose reductions for psychotropic medications, improper medication labeling, food safety violations, and infection control lapses during a COVID-19 outbreak.