F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on interview and record review, the facility failed to ensure a Registered Nurse was on duty in the
facility for a minimum of eight consecutive hours a day, seven days a week, for 6 of 26 weekend days
(11/01/2025, 11/02/2025, 11/15/2025, 11/16/2025, 11/29/2025, 11/30/2025) reviewed for RN coverage. The
facility failed to have RN coverage on the following dates in 2025:- 11/01/2025, 11/02/2025, 11/15/2025,
11/16/2025, 11/29/2025, 11/30/2025 This failure could place residents at risk of not having their nursing
and medical needs met, and other direct care staff not receiving sufficient oversight.Findings included:
Review of an undated excel file, covering the RN time stamp hours for weekend dates of the first fiscal
quarter of 2026 reflected insufficient RN coverage on the following dates of 2025. - 11/01/2025, 11/02/2025,
11/15/2025, 11/16/2025, 11/29/2025, 11/30/2025During an interview on 1/08/2026 at 2:56 PM, the DON
revealed she was responsible for RN weekend schedules. She said RNs were scheduled to work 6:00 PM 6:00 AM during the weekends and the RNs would take a break from 6:00 AM to 6:00 PM and return for the
next 6:00 PM - 6:00 AM shift (providing 6 hours of coverage in the morning and 6 hours of coverage in the
evening). The DON had thought the facility just needed at least 8 hours of coverage during weekend days,
not 8 consecutive hours. During an interview on 1/08/2026 at 3:20 PM with the ADM revealed he
understood the RN weekend day scheduled as RNs were scheduled from 6:00 AM - 6:00 PM, because that
was the schedule for weekdays. He stated the risk of not having an RN in the facility for 8 consecutive
hours was not having staff present with the clinical expertise of an RNs and knowledge to make decisions
for (a resident's) life. The facility did not have a policy regarding nurse staffing.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
455903
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455903
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Lodge Nursing & Rehabilitation
3800 Marina Dr
Lake Worth, TX 76135
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview and record review, the facility failed to provide safe and secured storage of
drugs and biologicals by not keeping medication in locked compartments, for 1 of 5 carts reviewed for
medication storage in that:LVN A failed to lock treatment cart while not in use. This failure could result in
physical injuries to residents; drug diversions, ingestion of medications causing adverse effects and
violation of HIPAA (Health Insurance Portability and Accountability Act). Findings includedIn an observation
on 1/6/2026 at 9:10am, treatment cart in hall 400 was unlocked when not in use. Inside treatment cart was
Resident #1's silver sulfa cream, wound supplies, 2 pairs of scissors, and 2 bottles of wound cleaning
liquid. Treatment cart was unlocked and not in use for 5 minutes.In an interview on 1/6/2026 at 9:15am with
treatment nurse. She stated medication cart and treatment cart should be locked at all times due to risk of
injuries to residents and HIPAA violation. She stated a resident could have gotten ahold of would cleaning
liquid and caused chemical injuries. She also stated a resident could have sustained physical injuries using
the scissors in an unlocked cart. She stated she forgot to lock the wound cart when she walked back to
medication room to get wound supplies to refill the cart. In an interview on 1/8/2026 at 2:30pm, the DON
stated that all carts should be locked at all times when not in use. She stated residents could have access
to medications or biologicals or medical tools in the carts that could cause harm. The DON also stated that
nurses were to lock all carts even if they were going to step away for a brief moment. She stated all nurses
were trained to lock all carts when carts are not in use. Review of facility's policy, Medication Administration
Procedures, dated 10/25/2027, stated .the medication cart must be completely locked, or otherwise
secured.
Event ID:
Facility ID:
455903
If continuation sheet
Page 2 of 2
