The breakdown occurred at Lake Village Nursing and Rehabilitation Center, where a Habilitation Coordinator recommended the positioning wedge during a March 4 interdisciplinary team meeting. The recommendation never made it into the resident's care plan.
Resident #1 had been at the facility for a long time and received ongoing specialized services under federal screening requirements for people with intellectual disabilities. During the March meeting, the Habilitation Coordinator approved the positioning wedge because the resident leaned to one side.
Nobody followed through.
The current MDS Coordinator told inspectors on September 16 that she wasn't working at the facility when the March care plan meeting was held. The previous MDS Coordinator was no longer employed there. She said she wasn't aware of the request for a positioning wedge, though she acknowledged that if a request for services required follow up, the MDS Coordinator was responsible for that.
The Director of Nursing said during a September 16 interview that staff met each morning to discuss care plans and interventions. She stated she was unaware a positioning wedge was recommended for Resident #1 on March 4. When she printed the resident's care plan, it showed the recommendation for a repositioning wedge. But page 7 of the plan, where changes would be documented, reflected no changes to his care plan.
The resident had his last care plan meeting on August 25. By then, it reflected a repositioning wedge was not needed.
The Administrator said after interdisciplinary team meetings, staff members discussed items that needed follow up and he followed up with the MDS Coordinator to ensure care plans were complete. He told inspectors he was not told Resident #1 needed a positioning wedge or the facility would have already purchased one. He said it was important for the facility to provide recommended services to ensure residents' needs were met.
During a telephone interview on September 19, the Habilitation Coordinator confirmed she had recommended the repositioning wedge during the March 4 interdisciplinary team meeting because Resident #1 leaned to one side, and she had approved it. She said the nursing facility emailed her about the state surveyor visit requesting information about Resident #1.
The facility requested an interdisciplinary team meeting. She scheduled one for October 1 to evaluate the resident's needs.
The facility's policy on resident assessment requires proper screening using state-specified procedures to determine if individuals require the level of services provided by a nursing facility and whether they require specialized services for intellectual disabilities.
The inspection found the facility failed to ensure that each resident's care plan was developed and implemented in accordance with the resident's comprehensive assessment. The violation affected few residents and resulted in minimal harm or potential for actual harm.
Six months passed between the specialist's recommendation and the facility's recognition that it had failed to act. The resident continued leaning to one side without the positioning aid that had been specifically approved to address the problem.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lake Village Nursing and Rehabilitation Center from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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