Federal inspectors found the facility's administrator, who is also a registered nurse, admitted that "apparently no one looked at the culture" results that showed the prescribed antibiotic Cipro was resistant to the organism causing the resident's urinary tract infection.
The resident, identified as Resident #14, had been given a urinalysis on July 29, 2024. Lab results showed a confirmed urinary tract infection, but the culture revealed Cipro was resistant to the specific bacteria. Despite receiving these results on July 31, staff continued administering the ineffective antibiotic twice daily through August 11.
The resident received Cipro starting July 30 at 8:00 AM and continued getting the useless medication for nearly two weeks after the facility knew it wouldn't work.
Meanwhile, another resident diagnosed with schizophrenia received three different psychiatric medications without any documented behavior monitoring for six months. Resident #9 had been prescribed the anti-psychotic Haloperidol since February 5, the anti-anxiety medication Buspirone since February 16, and had Ativan added to their regimen on July 28.
The resident's care plan documented "anxious/restless behavior as evident by calling out for help loudly without a need" and noted "a history of providing false information to family and staff for attention seeking purposes."
But medication administration records from February through August 2024 contained no behavior monitoring documentation whatsoever.
When asked about the missing monitoring, the new Director of Nursing, who had been in the position for only three weeks, initially claimed behavior documentation was "part of the documentation in the eMAR." Shown the complete absence of such records, the director became "unsure and referred the question to the MDS Coordinator."
The MDS Coordinator explained that behavior monitoring was supposed to be part of a "batch order set" used during admissions. She said "the order set may have fallen off during one of the resident's readmissions and no one caught it."
Monthly pharmacy recommendations from February through July 2024 contained no mention of the missing behavior monitoring, despite federal requirements for such oversight of psychiatric medications.
The consultant pharmacist, reached by phone during the inspection, was "unable to review his records" and promised to check later. By the time inspectors concluded their visit, no additional information had been provided.
Laboratory services proved equally problematic. Resident #9 had orders for blood work on July 22 that were never completed. The Director of Nursing searched the laboratory website and found that four other residents had labs drawn on July 22 and one on July 23, but could locate no results for Resident #9.
"The DON reviewed the laboratory service binder and could not find any requisition page for 07/22/24 or 07/23/24, thus was unable to determine why the labs were not drawn as per order," inspectors wrote.
Another resident, #72, had blood work ordered for August 9 that wasn't completed until August 12. A urinalysis ordered the same day was never done at all. When asked why, a registered nurse said samples might be "thrown out" if not labeled correctly or if they sat too long before the lab service arrived.
The facility's infection control failures extended beyond medication management. Resident #14, who had the indwelling urinary catheter, should have been under Enhanced Barrier Precautions requiring staff to wear gowns and gloves during high-contact care activities.
The facility's own policy, implemented April 1, 2024, states that Enhanced Barrier Precautions "should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device."
On August 11, inspectors found no precaution sign on the resident's door and no gowns available. The resident told inspectors that "staff wear gloves but they don't wear gowns during care."
By August 12, an Enhanced Barrier Precautions sign had appeared on the door, but staff remained confused about the requirements. A certified nursing assistant said she had been "told me to put on a gown since I was opening an item on [Resident #14] meal tray."
Another CNA performing catheter care said the overnight nurse told her "the antibiotic for his ESBL was up yesterday" and today's nurse thought "it was up today, so I used the gown to be safe." When shown the Enhanced Barrier Precautions sign, the aide read it and said, "I guess I need to wear the gown."
The aide admitted she "did not know about the EBP or the need to wear PPE for a resident with a urinary catheter" and added, "I don't think he had that sign or PPE when I worked last time, and he had the Foley."
A registered nurse interviewed about the precautions incorrectly believed they were "for the ESBL in his urine." When shown the Enhanced Barrier Precautions sign, the nurse "was unaware of the use of PPE during care."
Chart review revealed no ESBL in the resident's urine and no medical indication for contact isolation. Inspectors found no physician order for Enhanced Barrier Precautions despite the resident's indwelling catheter.
The Director of Nursing said the last staff training on Enhanced Barrier Precautions had occurred February 14, 2024. Although the facility implemented a new policy on April 1, "no in-services were completed with staff following the implementation of the new policy which includes EBP for urinary catheters."
Basic operational failures compounded the clinical problems. The dining room menu posted for residents had been wrong for days. On August 11, the daily menu still showed Monday's offerings despite being Sunday. It promised Cracker Crumb Cod, Potato Wedges, Broccoli, Roll, and Brownie for lunch.
Instead, residents received Turkey Shepherd's Pie, Dinner Roll, and Cheesecake.
A resident's family member approached inspectors while they examined the posted menus. "If you can understand the logic of those menus posted, you are a better person than I am," the person said. "That daily menu posted on the outside of the dining room has been there since last Monday. It would be nice to know what's being served."
The Certified Dietary Manager, returning from vacation, acknowledged that "the daily menus were not changed in my absence." She had corrected the daily menu that morning but said the weekly menus posted on the bulletin board showed "Week 1" when they should have indicated "Week 5."
The inspection revealed a facility where basic systems for medication management, infection control, laboratory coordination, and daily operations had broken down simultaneously. Resident #14 continued receiving ineffective antibiotics while staff remained confused about infection precautions. Another resident's psychiatric medications went unmonitored for months while lab work went undone and families couldn't determine what their loved ones would be served for lunch.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hidden Lakes Senior Living Community from 2024-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
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