Lake Mills Care Center
Inspection Findings
F-Tag F0697
F 0697 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
heard it from the nurses station. Staff A reported Resident #1 was 3 feet away from the bed and the walker and wheelchair were next to the bed. Staff A verbalized she tried to get Resident #1 to wait but she wouldn't wait. Staff A reported Resident #1 was unsteady walking so she went right to her. Staff A reported she was walking behind Resident #1 on the left side and Resident#1 turned quickly toward the bathroom. Staff A reported she couldn't get behind Resident #1 and Resident #1 slipped and fell back against the door and facing Staff A. Staff A verbalized as Resident #1 was sliding to the floor she was supporting Resident #1's head. Staff A reported a little ways off the floor Resident #1 lost her footing and dropped to the floor about 2 feet from the floor. Staff A verbalized Resident #1 dropped to her left side with legs facing toward the bathroom. Staff A reported she can't remember for sure if Resident #1's legs were bent or not. Staff A reported Resident #1 sat herself up and leaned her back against the door. Staff A reported Staff B came in and Staff A talked about the machine to get Resident #1 up and Resident #1 started to try and get herself up. Staff A verbalized prior to Staff B coming in Staff A assessed range of motion on Resident #1. Staff A reported Resident #1 complained of pain to her legs. Resident #1 could lift and rotate her legs. Staff A reported she asked Resident #1 to point to where it hurt and Resident #1 pointed to the leg. Staff A reported Resident #1 could not rate the pain. Staff A reported no shortening noted at the time. Staff A reported she knew Resident #1 hit her leg. Staff A reported the pain was not a lot when moving Resident #1 and once in bed she rated it worse. Staff A reported Resident #1 verbalized it as the worst pain ever.
Staff A reported that is why she documented the pain score at a 10. Staff A reported at the time of the fall
the facility did not call the doctor with every fall. Staff A reported she gave Resident #1 tylenol and around 5:15-5:30 AM Resident #1 was sleeping. Staff A reported Resident #1 was putting her call light on once Staff A gave her the tylenol and she kept asking for medication. Staff A reported she does not remember staff reporting pain for Resident #1. Staff A verbalized Resident #1 had aches and pain but the pain had not been localized. Staff A reported it is per nursing discretion for calling the doctor. On 10/16/25 at 9:30 AM
The Director of Nursing verified the facility did not do education on pain, assessment of pain and when to notify the physician with falls. She reported she was not aware of Resident #1 having the severe pain that was reported by the staff working. On 10/16/25 at 12:02 PM Staff E, LPN reported she got a report at 6AM
on 7/21/25 and then got her medication cart ready. Staff E reported she went down west hall and started a medication pass when she heard yelling at around 6:45 AM coming from room [ROOM NUMBER] window side (Resident #1's bed). Staff E reported Resident #1 was yelling out Help me! Help me! I'm in so much pain. Staff E reported Resident #1's eyes were red and she was facial grimacing so Staff E knew it was really bad. Staff E reported she forgot to chart in her documentation that Resident #1's left leg was abducted out and wouldn't let Staff E move her. Staff E verbalized she called the son because he visits frequently and told him Resident #1 needed to go to the hospital to be checked out because she was in a lot of pain and the staff could not move her. Staff E then sent Resident #1 by ambulance to the hospital Emergency Department (ED) to be further evaluated. Staff E reported Resident had mild aches and pains but never acted like how she was with the severe pain. On 10/16/25 at 1:05 PM Spoke with Staff F, CNA reported on 7/21/25 when she did walk through at 6 AM, Resident #1 was sleeping in bed. At around 6:45 AM Staff F went in to see if Resident #1 would want to get up for breakfast. Staff F reported Resident #1 began yelling out she was in pain. Staff F reported she could tell it in her eyes she was in pain. The nurse came in right away when she started yelling. The facility policy titled Fall Occurrence with a revised date of February 2024 lacked direction for staff in relation to pain with falls, what to do for the pain and when to notify the physician in relation to the pain.
Event ID:
Facility ID:
If continuation sheet
Lake Mills Care Center in Lake Mills, IA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Lake Mills, IA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Lake Mills Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.