The Lighthouse at Lakeside Village

Licensure reference: 175 NAC 006.04(A)(iii) Based on record review and interview, the facility failed to ensure criminal background checks were completed on 1 [Nurse Aide A] of 5 sampled staff members. The facility had a total census of 51 residents. Findings are: A review of background screening checks completed on 3/19/24 for Nurse Aide A did not reveal a completed criminal background check. A review of employee report dated 5/27/26 revealed Nurse Aide A had a hire date of 3/18/24. In interviews on 5/27/26 at 12:37 PM and 4:05 PM, Human Resource Business Partner confirmed a criminal background check had not been completed on Nurse Aide A due to Nurse Aide A being a minor. Human Resource Business Partner reported that an additional request would need to be made to the vendor in order to have a criminal background check completed on an employee who is a minor. A review of facility policy titled Abuse-Prevention and Reporting dated 4/7/26 revealed the following under the Pre-hire Screening section:- All applicants for employment in the facility shall, at a minimum, have the following…

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 allegations of abuse and significant injury were reported to Adult Protective Services within 2 hours for 2 [Residents 1 and 2] of 3 sampled resident and failed to ensure an investigation report was submitted to the state agency within 5 working days for 3 [Residents 1, 2, and 3] of 3 sampled residents. The facility had a total census of 51 residents. Findings are:A.A review of facility Abuse/Neglect Report dated 5/7/26 revealed an incident of potential abuse involving Resident 2 occurred on 5/3/26 before dinner. The description of the incident in the report revealed that Nurse Aide A had observed Nurse Aide B was being rough with Resident 2 by grabbing Resident 2's wrists and pulling on them. Nurse Aide A reported the occurrence to Licensed Practical Nurse D who did an assessment of Resident 2. Nurse Aide B was sent home. According to the Abuse/Neglect report, the facility completed an investigation that included interviews with 2 other staff…

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.

Licensure Reference Number 175NAC 12-006.11(E) Based on observation, interview, and record review; the facility failed to ensure expired food was discarded on or before the expiration date and failed to ensure opened food items were sealed and dated. The facility also failed to perform hand hygiene prior to and after touching soiled items while preparing food which had the potential for food borne illness. The facility also failed to measure items according to the recipe while preparing food. This had the potential to affect 30 out of 31 residents who consumed from the main kitchen in the facility. The facility census was 31. Findings are: A. An observation during the initial kitchen tour of the main kitchen on 3/6/25 at 12:22 PM revealed the dry storage area had two bags of corn flakes opened with no date, and a third bag opened with a date of 12/23. One bag of premier white chips opened with no date, one small bin of white chips with no lid, one can of coconut pecan frosting with expiration date of March 21, 2023. One 25 pound bag of lentil beans opened with a date of 9/18/24 in a…

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 interview and record review; the facility failed to transmit a Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used for care planning) record to the Centers for Medicare and Medicaid Services (CMS) within the prescribed time frames for 1 (Resident 6) of 1 sampled resident. The facility census was 31. Findings are: Record review of the Resident Assessment Instrument (RAI) manual revealed the facility is required to transmit the MDS within 14 days of completion. Record review of Resident 6's death tracking record with an assessment reference date (ARD) of 11/19/24, revealed the assessment was completed on 12/2/2024 but was not transmitted to CMS. An interview with the MDS Specialist (MDSS) on 03/10/2025 at 12:01 PM revealed that the MDS was marked as not to be transmitted to CMS. The MDSS confirmed the record should have been submitted to CMS. An interview with the Corporate Nurse Specialist (CNS) on 03/10/2025 at 3:46 PM confirmed the facility follows guidelines in the RAI manual for MDS transmission.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interview; the facility failed to update the Comprehensive Care Plan (CCP, a written interdisciplinary plan detailing how to provide quality care for a resident) to accurately reflect code status for 2 (Residents 5 and 12) of 2 sampled residents. The facility census was 31. Findings are: Record review of a facility policy entitled Care Plans-Comprehensive dated [DATE] revealed that the facility develops a comprehensive care plan for each resident which would include measurable objectives and timetables designed to meet the resident's medical, nursing, mental, and psychosocial needs through compassionate, trauma informed care, as identified in the comprehensive assessment. The policy identified that the care plan is periodically reviewed and revised by the interdisciplinary team after assessment. A. Record review of Resident 5's Census List dated [DATE] revealed the facility admitted the resident on [DATE]. Record review of Resident…

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 Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review; the facility failed to implement interventions to prevent the potential for hot liquid burns for 1 (Resident 5) of 2 sampled residents. The facility census was 31. Findings are: A record review of the facility's policy entitled Hot Liquids Safety dated 2/16/22 revealed that the facility would have a process in place to assess risk of injury from hot liquids so appropriate interventions could be implemented to reduce the risk of burns. A record review of Resident 5's Census List dated 03/11/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 5's Diagnosis List dated 03/10/2025 revealed the resident had diagnoses of non-ST elevation myocardial infarction (heart attack), metabolic encephalopathy (a brain dysfunction caused by a problem with the body's chemical processes), need for assistance with personal care, visual hallucinations, psychotic disorder with delusions,…

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.

Licensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview, and record review; the facility failed to ensure a medication error rate of 5% or less as evidenced by three errors out of 25 opportunities and resulted in a medication error rate of 12%. This affected two (Resident 1 and Resident 36) out of three residents sampled. The facility census was 31. The Findings are: A. A record review of an admission Record indicated the facility admitted Resident 36 to the facility on 2/20/25 with a diagnosis of periprosthetic fracture around internal prosthetic right hip joint and age-related osteoporosis without current pathological fracture. An observation on 03/10/25 at 7:12 AM of medications for Resident 36 revealed Register Nurse (RN)-A administered the following: Acetaminophen 500 milligram (mg) take 2 tablets by mouth three times a day. Do not exceed 4 grams in one day. For pain control. Alendronate 70 mg take 1 tablet by mouth weekly with full glass of water on an empty stomach, sit up for 30 minutes, no food, medications, or beverages for 30 minutes. For age…

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 Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) was accurate and coded to reflect Hospice [End of Life] Services for Resident 1 and no intravenous (IV) fluid use for Resident 10. The sample size reviewed was 13. The facility census at the time of the survey was 31. Findings are: A. Record review of the Clinical Census Report revealed that Resident 1 was admitted to the facility on [DATE]. Resident 1 was admitted to Hospice services on 1/19/22 Record review of Resident 1's Comprehensive Care Plan [CCP, a interdisciplinary comprehensive plan that detailed care of the resident] dated 1/8/24 revealed that Resident 1 had an overall decline in health and had a terminal prognosis related to advanced Alzheimer's disease. Record review of Resident 1's MDS dated [DATE] revealed diagnoses that included Non Alzheimer's Dementia. The MDS revealed that Resident 1…

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.

Licensure Reference Number 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure it was free of a medication error rate of 5% or greater. Observations were made of 25 medications administered which revealed 2 errors resulting in an error rate of 8%. The medication errors affect 2 (Resident 8 and 25) of 3 sampled residents. The facility staff identified a census of 31. Findings are: Record Review of Resident 8's Medication Summary printed on 04-03-2024 revealed an order for mucous relief 600 mg by mouth twice a day. Do not crush. An observation on 04-03-2024 at 7:40 AM of Care Partner (CP)-B administering medication for Resident 8 revealed CP-B prepared mucous relief 600 mg by placing the medication into a med pouch, crushing medication and then mixing the medication in applesauce. CP-B took the prepared medication and administered it to Resident 8. An interview with CP-B on 04-03-2024 at 7:55 AM confirmed that CP-B should not have crushed the mucous relief tablet. An interview with Registered Nurse (RN)-E on 04-03-2024 at 1:37 PM…

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.

175 NAC 12-006.17 Based on observation, record review and interview the facility failed to ensure linens were not exposed to cross contamination as evidenced by placing washcloths into the sink and failed to perform hand hygiene and glove changes during personal cares for 2 residents (Resident 2 and 20) of 7 sampled residents observed. The facility identified census was 31. Findings are: Record Review of the facility policy Hand Hygiene and Glove Usage dated 03-09-2021 revealed the following: -Policy Statement: It is the policy of the facility that hand hygiene for residents and staff will be performed to avoid the spread of pathogens. The use of gloves is to protect from potential exposure to blood, body fluids and/or other potentially infectious material with providing care. Gloves do not eliminate the need for hand hygiene. Hand Hygiene is required before putting on gloves and after removing gloves. -Under the section identified as Definitions revealed the following: -Hand Hygiene-Clean hands at appropriate times: -Before and after providing care to or handling resident…

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 175 NAC 12-006.09B Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) reflected the current status of the resident at the time of the assessmenht regarding falls for Resident 16 and discharge for Resident 32. This affected 2 of 14 residents sampled for MDS accuracy. The facility census was 33. Findings are: A. An initial interview with Resident 16 on 3/15/23 at 11:02 AM revealed that the resident had fallen at home prior to the hospitalization resulting in the nursing home admission. A review of the resident's hospital History and Physical dated 2/20/23 revealed that the reason for the emergency room visit was that the resident had a GLF (Ground Level Fall), on ground for 36 hours. A review of Resident 16's Medical Diagnosis page printed 3/16/23 at 9:21 AM revealed the resident was admitted to the facility on [DATE] with diagnoses of Unspecified Fall, Initial Encounter, and Fall on Same Level,…

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 Licensure Reference Number 175 NAC 12-006.09D3(5) Based on record review and interview; the facility failed to follow the facility's bowel protocol to prevent constipation for one (Resident 1) of one sampled resident. The facility census was 33. Findings are: In an interview on 3/15/23 at 1:44PM, Resident 1 revealed that Resident 1 had gone four days at times without a bowel movement. Record review of Resident 1's 30 Day Bowel Elimination Task, dated 2/19/23 to 3/20/23, revealed that Resident 1 went from 2/20/23-2/22/23, 2/27/23-3/1/23, 3/5/23-3/8/23, 3/10/23-3/12/23 and 3/14/23-3/16/23 without a bowel movement. Record review of Resident 1's current orders, dated 3/20/23, revealed orders for the following: -PEG3350 powder (a medication to prevent constipation) mix 17 grams (1 capful) in 4-8 ounces of liquid every day as needed (PRN). Indication for use: constipation -Milk of Magnesia suspension (a medication to treat constipation) 1200/15 milliliters (ml), take 30ml once daily PRN for constipation -Enema…

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 Licensure Reference Number 175 NAC 12-006.09D4 Based on record review and interview; the facility failed to ensure a restorative nursing program per therapy recommendation was initiated for 1 (Resident 1) of 3 sampled residents. The facility census was 33. Findings are: In an interview on 3/15/23 at 1:43PM Resident 1 revealed that Resident 1 had not received restorative care. A review of Resident 1's Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 1/31/23, revealed that Resident 1 had an impairment to both of Resident 1's lower extremities and revealed no documentation that a restorative nursing program had been completed. A review of Resident 1's occupational therapy Discharge summary, dated [DATE], revealed the recommendation for a restorative ROM (Range of Motion) program. The discharge summary further revealed that the information had been issued to the resident and to the restorative nursing staff with the…

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.