Lake County Nursing And Rehabilitation Center

F-F925.

There was no evidence the facility had identified, developed, or implemented action plans and/or continued to monitor any corrective actions taken when these deficiencies were cited previously.

During an interview on 8/9/24 at 11:30 a.m., the Administrator indicated there was no Performance Improvement Plan (PIP) in place for the prevention of gnats. He was aware there was a gnat problem and has had pest control coming in on a weekly basis, however, they did not always treat for gnats. He had asked the pest control company for a copy of the current contract they had previously signed with the facility so he could look at it and make revisions if needed.

3.1-52(b)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 155653 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155653 B. Wing 08/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harbor Health & Rehab 5025 McCook Ave East Chicago, IN 46312

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10770

Residents Affected - Some Based on observation and interview, the facility failed to ensure the residents' environment was in good repair related to marred walls, loose baseboards and missing bolts around the toilet for 1 of 2 floors observed. (First Floor)

Findings include:

During the Environmental Tour on 8/9/24 at 9:30 a.m. with the Maintenance Director, the following observed:

First Floor

a. room [ROOM NUMBER] - The cove base was pulling away from the wall near the entrance of the room.

The walls were marred under the chair rail. The base of bathroom door was scratched and marred. There were 2 residents who resided in room and 4 residents shared the bathroom.

b. room [ROOM NUMBER] - The wall the behind the bed was marred and gouged. There was 1 resident who resided in the room.

c. room [ROOM NUMBER] - The door frame was marred by the closet and the cove base was loose in the entry way of the room. The walls in the bathroom were marred. There were 2 residents who resided in the room and shared the bathroom.

d. room [ROOM NUMBER]- The bathroom door frame was marred and the paint on the walls was chipped.

The bolts were exposed at the base of the toilet. There was 1 resident who resided in the room and 3 residents shared the bathroom.

e. room [ROOM NUMBER] - The bathroom door frame was marred and the paint was chipped. There were 2 residents who resided in the room and 3 residents who shared the bathroom.

During an interview on 8/9/24 at 9:30 a.m., the Maintenance Director indicated all the above was in need of repair.

3.1-19(f)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 155653 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155653 B. Wing 08/09/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Harbor Health & Rehab 5025 McCook Ave East Chicago, IN 46312

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 48055 potential for actual harm Based on observation, record review, and interview, the facility failed to ensure the residents' environment Residents Affected - Few was free of pests related to gnats for 1 of 1 residents observed with gnats in their room. (Resident 33)

Finding includes:

On 8/5/24 at 10:12 a.m., Resident 33 was observed lying in bed with gnats flying in the room and landing on her bed linen and right lower leg wound dressing.

On 8/5/24 at 11:04 a.m., the Wound Nurse was observed entering the resident's room and attempting to complete wound care. There were gnats observed in the air, on the resident's gown, and on the wound dressing. The wound nurse removed several layers of the bandages and several gnats were observed inside

the bandages and on the resident's open ulcerations to the right lower leg. During an interview at that time,

the Wound Nurse indicated they were attempting to get rid of the gnats and had put a work order in for treatment. There were gnat strips hanging in the room, and she was aware the gnats were flying on and around the wound during the treatment. The Wound Nurse indicated the Director of Nursing was also aware and saw the gnats on the wound and bandages.

The record for Resident 33 was reviewed on 8/5/24 at 9:10 a.m. Diagnoses included, but were not limited to, pressure ulcers, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The resident also received hospice services.

The Significant Change Minimum Data Set (MDS) assessment, dated 7/8/24, indicated the resident was cognitively intact, and had pressure ulcers upon admission.

A Pest Control document, provided by the Administrator on 8/5/24 at 1:48 p.m., indicated on 7/24/24, fruit flies were treated in the following areas; the laundry room, restrooms, kitchen, main kitchen, the kitchen dish room, the janitor closet, and kitchen janitor closet.

The pest control company had been at the facility and treated bed bugs and cockroaches on 7/30/24 and 8/2/24. Gnats were not treated anywhere in the facility on either of those visits.

During an interview on 8/5/24 at 3:54 p.m., the Administrator indicated the resident was moved to a different room and the room was deep cleaned.

During an interview on 8/5/24 at 4:05 p.m., the Wound Nurse retracted her statement about seeing the gnats

on the resident and on the wound. She indicated her statement was misunderstood regarding the gnats being in the room, on the resident's wound, and on the bandages.

A facility policy titled, Safe Environment, provided by the Administrator on 8/9/24 at 11:00 a.m., indicated .the facility will maintain an effective pest control program so that the facility is free of pests and rodents .

3.1-19(f)(4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 155653