Haven of Lakeside

Inspectors wroteBased on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure that a pressure ulcer was assessed and treated timely and according to physician orders for one resident (#10). The deficient practice could lead to deterioration of a resident's medical condition.-

Inspectors wroteBased on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure that the medical record was complete, accurate, and readily accessible for one resident (#10). The deficient practice could lead to care team members not being aware of a resident's status.-

Inspectors wroteBased on clinical record review, interviews, and facility documentation, the facility failed to implement their policy on abuse regarding reporting and investigation of an allegation of abuse for one of 3 sampled resident (#51). The deficient practice could result in residents not protected from further abuse.

Inspectors wroteBased on clinical record review, interviews, and facility documentation, the facility failed to ensure that an allegation of abuse for one of 3 sampled residents (#51) was reported to the State Agency, Ombudsman and law enforcement and failed to report the results of the investigation to the State Agency within 5 working days of the incident as required. The deficient practice could result in abuse not being reported and residents not protected from further abuse.

Inspectors wroteBased on clinical record review, interviews, and facility policy review the facility failed to ensure an allegation of abuse for one of 3 sampled residents (#51) was thoroughly investigated. The deficient practice could result in appropriate corrective action not taken to protect residents from further abuse.

Inspectors wroteBased on record review, staff interviews, review of facility documents and policy, [NAME] Nursing Drug Handbook, and Medlineplus.gov website, the facility failed to ensure medications for four residents (#24, #64, #9, #86) were administered as ordered by the physician. The deficient practice could place residents safety at risk and could result in resident's not receiving the treatment that they need. Number of residents sampled: 20Number of residents cited: 4Findings include:-Resident #24 was admitted to the facility on [DATE] with diagnoses that included hypertension, depression and Non-Alzheimer's Dementia. The care plan dated March 17, 2023 revealed the resident was on opiate medication and was at risk for pain related to pain and history of right hip fracture and generalized discomfort. Intervention included to administer medications as ordered. [...]

Inspectors wroteBased on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents.

Inspectors wroteBased on observation, staff interviews, facility documents and policy review, the facility failed to ensure current nurse staffing information was accurate for actual hours worked by licensed and unlicensed direct care nursing staff and that the census was updated daily to reflect the actual number of residents. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information and census.

Inspectors wroteBased on observations, record review, staff interviews, review of facility documentation and policy, [NAME] Nursing Drug Handbook and Medlineplus.gov website, the facility failed to ensure that medication error rates were not five percent or greater. The deficient practice could place residents safety at risk.

Inspectors wroteBased on documentation, staff interviews, and facility policies the facility failed to ensure that four staff members (#21, #58, #1, & 55) received Disaster training. The deficient practice could result in staff not being familiar with the procedures to follow in the event of an emergency and/or disaster.

Inspectors wroteBased on documentation, staff interviews, and facility policies the facility failed to ensure that two staff members (#21 and #58) are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. The deficient practice could result in staff not being familiar with residents' rights.

Inspectors wroteBased on documentation, staff interviews, and facility policies the facility failed to ensure that one staff member (#21) was educated on abuse, and that seven staff members (#21, #58, #24, #1, #12, #55 & #11) and one nursing aide (NA) student (staff #255) received Elder Justice Act training. The deficient practice could result in staff not being familiar with the detection, prevention and reporting of abuse, neglect, and exploitation of property.

Inspectors wroteThe facility failed to ensure that the advance directive was consistent and correct for one Resident.(#7)Number of residents sampled: 20Number of residents cited: 1 Based on clinical record review, staff interviews, and facility policy and procedure, the facility failed to ensure that the advance directives were consistent throughout one (#7) of twenty sampled resident's clinical records. The deficient practice could result in residents receiving services that are not in accordance with their wishes.

Inspectors wroteBased on record review, staff interviews, review of facility documents and policy, the facility failed to ensure one resident (#14) was referred for Level II Pre-admission Screening and Resident Review (PASRR). The deficient practice could result in residents not receiving appropriate services to meet their needs. Number of residents sampled: 20Number of residents cited: 1Findings include:Resident #14 was initially admitted on [DATE] and was readmitted to the facility on [DATE] with a diagnosis that included myocardial infarction, depression, anxiety disorder, bipolar disorder, and schizoaffective disorder. A review of care plan dated January 3, 2024 revealed resident use antipsychotic and antidepressant medications related to schizoaffective disorder. [...]

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and facility policy and procedure, the facility failed to coordinate with hospice to ensure quality care and services for one resident (#29). The deficient practice could result in residents not receiving the appropriate interventions for their comfort and end of life services.

Inspectors wroteBased on observations, clinical record review, staff interviews and review of facility policies and procedure, the facility failed to ensure appropriate treatment and services was provided to 1 of 3 sampled residents (#22) with limited ROM.

Inspectors wroteBased on observations, staff interviews, review of facility documentations and policy, the facility failed to ensure that medications were secured and stored properly. The deficient practice could result in unauthorized access to medications and could place resident's safety at risk.

Inspectors wroteBased on documentation, staff interviews, and facility policies the facility failed to ensure that two staff members (#21, and #58) are educated on infection control and prevention. The deficient practice could result in staff not being familiar with process and procedures for the control and prevention of infection.

Inspectors wroteBased on documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#21, #58, #1, #55 & #11) received Dementia Care training. The deficient practice could result in staff not being familiar with process and procedures to care for residents with dementia.

Inspectors wroteBased on interviews, review of clinical record, and facility policy, the facility failed to protect the residents' (#26, #24, #4, and #6) right to be free from physical abuse by a resident. The deficient practice could result in physical and psychosocial harm. Regarding Resident #26 and Resident #24:-Resident #26 was admitted to the facility November 6, 2023, with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance, prediabetes, type 2 diabetes mellitus, chronic kidney disease, cardiomegaly, delirium due to known physiological condition, anxiety disorder, bradycardia, and adult failure to thrive. An admission minimum data set (MDS) assessment dated [DATE], revealed a brief interview for mental status (BIMS) score of 1, indicating severe cognitive impairment. Section C revealed the resident had inattention and disorganized thinking. [...]

Inspectors wroteThe facility failed to ensure an alleged violation involving two residents (#37 and #42) was reported to the State Agency. Based on clinical record review, resident and staff interviews, review of the facility documentation and policy, the facility failed to ensure an alleged violation involving two residents (#37 and #42) was reported to the State Agency (SA).

Inspectors wroteThe facility failed to ensure a complete investigation involving an alleged violation with two residents (#37 and #42) was conducted. Based on clinical record review, resident and staff interviews, review of the facility documentation and policy, the facility failed to ensure a complete investigation involving an alleged violation with two residents (#37 and #42) was conducted.

Inspectors wroteBased on clinical review, interviews and facility policy review, the facility failed to ensure that two residents (#75 and #10) were free from injuries from a preventable accident. The deficient practice could lead to serious injury or death to residents.

Inspectors wroteBased on interviews, review of facility documentation, and review of policy and procedures, the facility failed to implement their policy to report and investigate allegations of neglect for one resident (#8) and failed to protect a reporter from retaliation. The deficient practice could result in allegations of neglect not being reported and investigated timely, which could result in continuing neglect.

Inspectors wroteBased on interviews, review of facility documentation, and review of policy and procedures, the facility failed to assess a resident for a change of condition timely, and provide timely transfer to emergency services for one resident (#8). Additionally, the facility failed to obtain a physician order for administration of oxygen therapy according to professional standards for one resident (#8). The deficient practice could result in a delay of care for a resident, leading to a worsening medical condition, and could lead to a physician not being aware of a resident's respiratory status regarding oxygen use. Findings Include: -Regarding resident assessment and timely transfer to emergency services for Resident #8: [...]

Inspectors wroteBased on interviews, review of facility documentation, and review of policy and procedures, the facility failed to maintain a complete and accurate medical record for one resident (#8) regarding administration of oxygen therapy dose. The deficient practice could result in an incomplete medical record which could lead to interdisciplinary team members not being aware of a resident's respiratory status regarding oxygen use. Findings Include: Resident #8 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, post-polio syndrome, chronic pain syndrome, asthma, and dyspnea. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview or Mental Status (BIMS) score of 15, indicating intact cognition. [...]

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that four residents (#24, #68, #10, #12) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one of three sampled residents (#1) was not abused by another resident (#2). The deficient practice could result in residents being physically and emotionally harmed. Findings Include: -Regarding Resident #1: Resident #1 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage without loss of consciousness, metabolic encephalopathy, dementia, delirium, depression, and anxiety. The OBRA (Omnibus Budget Reconciliation Act) admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident's Brief Interview for Mental Status (BIMS) score was 99, which indicated severe cognitive impairment. [...]

Inspectors wroteBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to protect the rights of two residents (#24 and #15) to be free abuse by residents (#6 and #34). The deficient practice could result in residents being physically and mentally harmed.

Inspectors wroteBased on concerns identified during the survey, review of the facility assessment, staff interviews, Quality Assurance (QA) documentation, and policy review, the Quality Assessment and Assurance (QAA) committee failed to ensure the director of nursing (DON) attended the QAA meeting. The deficient practice can result in quality care concerns not being identified and corrected.

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure one resident (#31) was able to make choices about their care. The deficient practice could result in residents being denied the right to make their own choices.

Inspectors wroteBased on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that one resident (#304) was free from abuse by another resident (#20).

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure that alleged violations involving abuse were reported within required timeframe for one resident (#16).

Inspectors wroteBased on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure one resident (#27) received necessary services to maintain personal hygiene. The deficient practice may cause a decline or decrease in a resident's quality of life.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure baseline care planning as required for 4 residents (#1, #62, #64, and #88). The sample was 35 residents. The deficient practice could result in lack of resident involvement in the plan of care. Findings Include: -Resident #1 was admitted to the facility on [DATE] with diagnoses that included acquired absence of left leg above knee, anxiety disorder, chronic kidney disease, and chronic obstructive pulmonary disease. Review of the clinical record did not reveal documentation that the facility provided the resident and their representative with a summary of the baseline care plan as required. An interview was conducted on December 8, 2022 at 1:27 p.m. with the [NAME] President of Clinical Operations (staff #84). [...]

Inspectors wroteBased on clinical record review, staff and resident interviews and policy review, the facility failed to ensure one resident (#47) or resident's representative was able to participate in the care planning process. The sample was 35 resident. The deficient practice could result in residents and representatives not participating in and understanding their plan of care.

Inspectors wroteBased on clinical record review, facility documentation, staff interviews, and policy, the facility failed to ensure that an appropriate level of supervision was provided for one resident (#8) resulting in two another residents (#24 and #6) being slapped and grabbed. The sample was 7 residents. The deficient practice could result in other residents being physically harmed.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy, the facility failed to provide urinary catheter care as ordered to one resident (#64). Three residents were reviewed for urinary catheter/Urinary Tract Infection (UTI). The deficient practice could result in complications with indwelling urinary catheters, including infection. Findings Include: -Resident #64 admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease, flaccid neuropathic bladder, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was always incontinent and required total assist for toileting. Review of the physician's orders for August 23, 2022 revealed: [...]

Inspectors wroteBased on interviews, personnel record review, facility assessment review, and policy, the facility failed to ensure 2 staff (#26 and #89) possessed the competencies and skills needed to care for residents with behaviors. The deficient practice could result in a delayed and inappropriate response to deescalate behaviors.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure one resident (#64) receiving psychotropic medications received consistent monitoring for behaviors and side effects; failed to document the use of non pharmacologic interventions; and failed to ensure a PRN (as needed) antianxiety medication had a duration for treatment. Five residents were reviewed for medication use. The deficient practice could result in unnecessary medication use and adverse side effects.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to notify one resident (#1), or the resident's representative, and ombudsman in writing of the reason for the transfer/discharge. The sample size was 1. The deficient practice could result in residents not knowing their discharge rights.

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedure, the facility failed to notify one resident (#1), or the resident's representative of the bedhold and reserve bed payment policies at the time of transfer/discharge to the hospital. The sample size was 1. The deficient practice could result in residents not knowing their discharge rights.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure complete and accurate comprehensive Minimum Data Set (MDS) assessments for two residents (#62 and #64). The sample was 35 residents. The deficient practice could result in inadequate assessment of resident needs.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two residents (#1 and #64). The sample was 35 residents. The deficient practice could result in inadequate assessment of resident needs.

Inspectors wroteBased on personnel file review, staff interview, and job description, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in lack of appropriate activity programs for residents.

Inspectors wroteBased on clinical record review, observations, staff and resident interviews, and review of facility policy, the facility failed to assess for interventions for identified decreased Range of Motion (ROM)/contractures for one resident (#64) of two residents reviewed for positioning and mobility. The deficient practice could result in residents not receiving required services and a further decline in resident status. Findings Include: -Resident #64 admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Review of a care plan focus dated April 28, 2022 revealed the resident had impaired functional mobility with a goal to remain free from complications of impaired range of motion. [...]

Inspectors wroteBased on closed clinical record review, staff interviews, and policy review, the facility failed to provide pain management in a timely manner in accordance with physician's orders for one resident (#289). The sample size was 6 residents. The deficient practice could result in resident's pain not being managed timely. Resident #289 was admitted to the facility on [DATE] with diagnoses that included scoliosis surgery, fusion of spine, and hypertension. Review of the clinical record revealed the following physicians orders: -Oxycodone Tablet 5 milligrams (mg) 1 tablet by mouth every 6 hours as needed for pain level of 6 to 10. Order dated 11/22/22 10:00 am -Tylenol Extra Strength Tablet 500 mg (Acetaminophen) 2 tablet by mouth every 6 hours as needed for Pain Scale 1-5, not to exceed 3mg per 24/hour period. [...]

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure menus were followed in regard to food served. The deficient practice could place residents at risk of nutritional problems and dissatisfaction with their meals.