Lake Forest Place

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure R1, who is dependent on the staff for bed mobility, did not fall out of bed while the staff was providing care for 1 of 3 residents (R1) reviewed for falls in the sample of 3.The findings include:On 06/03/2026 at 10:29AM, R1 was lying in the bed on an air mattress.On 06/03/2026 at 10:29AM, R1 stated, the nurse was changing me. I was lying on the edge of the bed, then she grabbed ahold of the sheet underneath me, she pulled it out and it shot me over the side. She was alone, she should have had another staff member, usually there are two assisting me in bed. Luckly I was not seriously hurt, I do have bruises from the fall.On 06/04/2026 at 12:20PM, V4 CNA-Certified Nursing Assistant said, I was changing R1 by myself. I turned the top part of R1's body, I was not able to get to the other side to stop him from sliding off the bed.On 06/03/2026 at 12:52PM, V2 DON-Director of Nursing said, on 05/26/2026 I was told the CNA was changing R1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate supervision and implement swallowing precautions for a resident at risk for choking for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.The findings include:On 4/23/26 at 9:37 AM, R1 was well-groomed, seated in his wheelchair in the foyer. R1 leaned to his right side, he was slow to respond, and had some drool in the right corner of his mouth. R1 said he had some trouble swallowing a few days ago. R1 said he was taking big bites and eating too fast. R1 said he couldn't catch his breath, and the staff had to help him. R1 stated, I wouldn't say they saved my life, but they helped. R1 said he was eating pureed food when he choked. At 12 PM, R1 was feeding himself pureed turkey chili, garden vegetables, corn bread, and fries with a spoon. V5 (Restorative Certified Nursing Assistant (CNA) was positioned next to R1, watching him. R1 attempted to take big bites and eat quickly. V5 provided verbal cues…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure fall interventions were in place for a resident with a history of falls for 1 of 15 residents (R7) reviewed for safety in the sample of 15.The findings include:R7's Face Sheet printed on 1/26/26 listed a history of falling as a diagnosis.R7's Fall Care Plan with an initiated date of 7/7/24 showed R7 had fallen while at the facility and had a history of falling out of bed. Listed under interventions was the use a floor mattress. On 1/26/26 at 10:14 AM, R7 was in bed. There was no floor mattress on the floor next to R7's bed. The floor mattress was lying up against the wall near the head of the bed. There were no staff members, family, or care givers in the room. On 1/27/26 at 12:07 PM, V10 (Certified Nursing Assistant) said floor mattresses should be placed on the floor next to the bed when the resident is in bed.

Based on interview and record review the facility failed to secure narcotic medication after delivery from the pharmacy. This applies to one of three residents (R1) in the sample of seven reviewed for medication storage.The findings include:The facility reported incident report dated 8/4/2025 shows a narcotic was delivered to the facility from the pharmacy on 8/2/2025 at 7:11 AM for R1. On 8/4/2025 the narcotics could not be located.The facility face sheet for R1 shows she was admitted to the facility after a stay in the hospital for pneumonia and respiratory failure. R1 had a Physicians order for hydrocodone (narcotic pain medication) to be used as needed for pain. R1 was discharged from the facility on 8/4/2025 as planned. On 8/13/2025 at 10:30 AM the door to the nursing station was locked. V7 Unit Secretary came and unlocked the door for this surveyor and said, It's locked today because the state is in the building.On 8/13/2025 at 10:01 AM, V3 Registered Nurse said she was the day shift supervisor working the morning of 8/2/2025 when the narcotic was delivered from the pharmacy.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure dishes were washed in a manner to prevent cross-contamination and failed store thickener in a manner to prevent cross-contamination. This affects all 44 residents residing in the facility. The findings include: The facility's CMS 671 Form dated 12/10/24 shoed there were 44 residents residing in the facility. 1. On 12/10/24 at 10:08 AM, the surveyor, V3 (Dietitian), V4 (Director of Dining Services), and V8 (Dietary Manager) returned to the main kitchen. The dishwashing area was inside the door, to the left. The dishwashing station was a small square shaped area, with an opening to enter the area. The dirty dishes were stacked to the left of the dishwasher and directly across the area, from the dishwasher. The clean dishes were removed from the right side of the dishwasher and stacked against the adjacent wall. The 3 compartment sink was positioned to the right of the clean dishes (or on the opposite wall from the dishwasher). The additional dirty dishes were stacked at the end of the 3 compartment sink.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to check placement of a feeding tube prior to administering a nutritional supplement for 1 of 1 resident (R25) reviewed for feeding tubes in the sample of 12. The findings include: R25's face sheet printed on 12/12/24 showed diagnoses including but not limited to Parkinson's disease, dysphagia (difficulty swallowing), dementia, epilepsy, and protein-calorie malnutrition. R25's facility assessment dated [DATE] showed severe cognitive impairment and the use of a G tube for nutrition (gastrostomy tube-soft, plastic feeding tube that goes into the stomach). R25's December 2024 order summary report showed an order start dated 7/2/24 for: .enteral feeding give 1 carton (237 milliliters) of Jevity 1.5 calorie at noon per G tube . The same report showed orders start dated 7/1/24 to check placement of the G tube before administering medication or feedings. On 12/11/24 at 1:27 PM, V9 (Registered Nurse) administered R25's enteral feeding while he was in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 1 of 1 resident (R8) reviewed for infection control in the sample of 12. The findings include: On 12/10/24 at 11:19 AM, R8 had a PPE bin outside the door. There was a large sign on the door of the room that said, STOP Enhanced Barrier Precautions. The signage had illustrations to show gloves and gowns must be worn during high-contact resident care activities. The care activities included but were not limited to: dressing, transferring, and assisting with toileting when a urinary catheter was in use. This surveyor entered the room and R8 was standing at the sink while brushing his teeth. V11 (CNA-Certified Nurse Aide) was in the bathroom and wearing only gloves. V11 assisted R8 across the room using a gait belt and walker, then transferred him to an upright recliner. V11 emptied the garbage can and exited the room. V11 was not wearing a gown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident dignity was maintained during dining for 1 of 6 residents (R1) reviewed for dignity in the sample of 6. The findings include: R1's face sheet printed on 8/14/24 showed diagnoses including but not limited to atrial fibrillation, pulmonary embolism, malnutrition, Alzheimer's Disease, and dementia. R1's facility assessment dated [DATE] showed severe cognitive impairment and substantial/maximal staff assistance needed for eating. On 8/14/24 at 1:51 PM, V8 (R1's daughter) stated she was visiting R1 on the morning of 7/8/24 and found her seated in the group dining room wearing only a hospital type nightgown. V8 said R1 had a blanket draped over her shoulder's but nothing over the rest of her. V8 said she absolutely brought clothes to the facility including pajamas, the day prior. V8 said she immediately complained to staff. V8 was told that R1 was restless during the early morning hours and was taken to the nurse station in her nightgown.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure a homelike environment by allowing a damaged nightstand to remain in a resident room for 1 of 6 residents (R4) reviewed for environment in the sample of 6. The findings include: On 8/14/24 at 1:51 PM, V8 stated her aunt was a resident at the facility for about one week in July 2024. V8 said the nightstand in the room was damaged during the entire time. The top handle was hanging off and the left upper corner was missing a section. V8 said staff were repeatedly in and out of the room but the nightstand was never repaired or replaced. On 8/14/24 at 10:44 AM, the facility nightstand in the same room V8's aunt had resided in was observed. The handle was still falling off and the left, upper corner was heavily damaged. R4 was the resident currently residing in the room. R4 said it had been that way since she arrived at the facility. On 8/14/24 at 1:32 PM, V5 (Maintenance Technician) stated he was unaware of any complaints or work repair orders for the nightstand. V5 said items like nightstands can typically…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure a resident with a complicated feeding problem was assisted to eat by a qualified staff member for 1 of 3 residents (R3) reviewed for safe dining in the sample of 3. The findings include: On 05/08/24 at 11:35AM, V6 Resident Assistant was providing R3 bites of pureed food with a spoon. On 05/08/24 at 11:35AM, V6 said, this is R3. I am an Activity Specialist; I am not a CNA-Certified Nursing Assistant. I am trained to feed residents as a Resident Assistant. On 5/08/24 at 1:13PM, V7 Speech Therapist said, R3 has a treatment diagnosis of dysphagia related to age, Alzheimer's (disease), and dementia. Because of his Alzheimer's (disease) he is at risk for choking if he is not fed appropriately. The problem I was treating R3 for is an oropharyngeal dysphagia (difficulty moving food in the mouth in preparation to be swallowed and moving the food safely past the trachea without aspiration into the lungs). R3's current Physicians Orders dated May 2024 shows, multiple diagnoses including dysphagia. Diet Orders:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure urinary catheter bags were kept from resting on the floor and failed to secure the catheter tubing for 2 of 3 residents (R197 and R38) reviewed for catheters in the sample of 12. The findings include: On 1/8/24 at 11:22 AM, R197's urinary catheter bag was lying directly on the floor on the right side of her bed. On 1/8/24 at 11:41 AM, R38's urinary catheter bag was attached to her bed frame and her bed was low to the floor, therefore, resting directly on the floor, uncovered. On 1/8/24 at 2:03 PM, V6 and V7, Certified Nursing Assistants (CNAs) provided incontinence care to R38. R38's catheter tubing was not secured in any manner and was taut. After completing incontinence care, V6 and V7 positioned R38 on her back with the unsecured catheter tubing placed under her left leg. The drainage bag was hung on the bed frame, the bed was lowered and again the drainage bag was resting directly on the floor. On 1/8/24 at 2:31 PM, R197's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the discharge process was completed for a resident who left against medical advice for 1 of 2 residents (R42) reviewed for discharge in the sample of 13. The findings include: On 3/8/23 at 9:30 AM, R42 was not observed in the facility. R42's Progress Note dated 12/15/22 shows admitted [AGE] year old female from hospital brought in by family in wheelchair with diagnosis of urinary tract infection, possible pneumonia, dementia with history of hypertension, heart murmur. There are no other progress notes in R42's electronic medical record. The facility census dated 3/6/23 does not contain R42. On 03/08/23 at 9:40 AM, V2 Director of Nursing (DON) stated I'm not sure what happened to R42. I will have to ask the admitting nurse. R42 is not here currently. R42's Face sheet dated 3/8/23 shows R42 was admitted [DATE] at 2:24 PM and then discharged [DATE] at 5:00 PM. On 03/08/23 at 9:54 AM, V2 said he spoke with V5 Registered Nurse who…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a residents insulin vial was stored with open/expiration dates for 1 of 13 residents (R146) reviewed for medication storage in sample of 13. The findings include: R146's Face Sheet printed on 3/7/23 showed R146 to be an [AGE] year old female admitted to the facility with diagnoses which include: disease of pancreas and type 2 diabetes mellitus. R146's Physician Order Sheet printed 3/7/23 showed R146 having a short acting insulin order for 6 units three times a day in addition to a sliding scale dose before meals. On 3/6/23 at 11:45 AM, V5 Registered Nurse (RN) opened the med cart. R146's vial of short acting insulin was opened with no open date or expiration date written on the vial or the storage bag. V5 stated the nurse who opened the vial should have put an open and expiration date on the vial. The expiration date is 28 days after opening for insulin. On 3/8/23 at 11:25 AM, V10 Nursing Supervisor (RN) stated when an insulin vial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.