Lacoba Homes Inc

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment as free from safety hazards as possible when staff failed to transfer a with an appropriate placed gait belt (a transfer belt placed around the waist to assist with standing, walking, or transferring and to help prevent falls) and when staff were not aware of the best manner in which to transfer for one resident (Resident #8) out of 14 sampled residents. The facility census was 44. Review of the facility policy Assistive Lifting Devices, undated, showed the following:-The goal was to decrease possible injuries to all staff and/or residents when transferring, toileting, or ambulating;-Gait belt was to be implemented with all ambulation and transfer procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate infection control practices when staff failed to wash and/or sanitize hands before and during personal cares for one resident (Resident #8) out of 14 sampled residents. The facility census was 44. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure all residents were free from significant medication errors when staff failed to clarify orders for an antibiotic the resident was listed as allergic to prior to administration for one resident (Resident #1) resulting in a negative reaction to the medication administered. A sample of nine residents was reviewed in a facility with a census of 45. Review of the facility's policy entitled Infection Prevention and Control Policies: Antibiotic Stewardship, not dated, showed the following: -The antibiotic stewardship program is a set of commitments and actions intended to optimize the treatment of infections while reducing adverse events associated with antibiotic use. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to date bread products, lettuce, and cheese stored in the facility's kitchen. This had the potential to affect all 59 residents who consumed food prepared from the kitchen. Review of the facility's policy titled, Food Storage and Supply, undated, showed food is properly stored to preserve flavor, nutritive value, and appearance. Review of the undated storage instructions from the facility's bread vendor showed upon delivery store in freezer or thaw and store at room temperature for immediate use. Best used within seven days of thawing. 1. Observation during the initial kitchen inspection on 04/08/24, from 9:30 A.M. to 10:00 A.M., of bread products stored on the kitchen's bread racks, with the Dietary Manager (DM) present, showed the following: -One undated package of hamburger buns; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide thickened liquids in the prescribed consistency for one of one resident (Resident #37) who had a diagnosis of dysphagia (difficulty with swallowing) and received thickened liquids. A sampled of 21 residents was reviewed. Review of the facility's policy titled, Thickened Liquids, dated 2017, showed the following: -Thickened Liquids are often needed for individuals with difficulty swallowing; -The individual is evaluated by a speech language pathologist (SLP) and, after evaluation, the SLP orders the appropriate diet consistency and liquid consistency as needed. 1. Review of Resident #37's Speech Language Pathologist (SLP) Discharge summary, dated [DATE], showed the SLP discharge recommendations were for the resident to receive pureed consistencies food and nectar thick liquids. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent the misappropriation of residents' medications in the possession of the facility when one staff member (Licensed Practical Nurse (LPN) A) had medication in his/her possession that were for residents, including one resident (Resident #1) who the LPN took medication from the emergency kit (e-kit - a medication cart that contains emergency medication for residents) for and placed the medication packet in his/her wallet. Five residents were sampled and the facility census was 47. The facility Administrator and the Director of Nursing (DON) were notified of the Past Non-Compliance which occurred on 09/05/23. The facility staff began an investigation on 09/05/23 and suspended LPN A. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a bed-hold policy for two residents (Residents #15 and #22) who transferred to the hospital. The facility census was 42. Record review of the facility's (undated) policy titled Bed Hold showed the following: -The home will permit residents to retain their beds when they are discharged to the hospital or for therapeutic leave; -The facility will provide written information to the resident or their representative that specifies should the resident be transferred or discharged from facility with the intent of returning, the bed will be held upon request of the resident, their representative or responsible party; the facility must contact the resident or family representative to verify holding of the bed within twenty-four (24) hours of the transfer or discharge and document all attempts to notify; [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure one resident's (Resident #29) code status (if resident wished to receive cardiopulmonary resuscitation (CPR) to be given in case of respiratory or cardiac failure) was consistently documented throughout the resident's medical record. The facility census was 42. Record review of the facility's policy titled, Advanced Directives, no date, showed the following information: -It is the policy of this facility to ensure that a resident's choice concerning the development of advance directives relative to his/her refusal of medical surgical treatment be followed in accordance with the facility's advance directive policies and procedures; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #39) had an order for a catheter (a sterile tube inserted into the bladder to drain urine) and catheter care. The facility census was 42. Record review showed the facility did not provide a policy regarding catheter orders. 1. Record review of the Resident #39's face sheet (admission data) showed the following: -admission date of 5/16/22; -Diagnoses included retention of urine (difficulty urinating and completely emptying the bladder), chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), and type two diabetes mellitus (condition that occurs when the body cannot use glucose (type of sugar) normally) with diabetic chronic kidney disease. Record review of the resident's progress note dated 5/17/22, at 1:30 P.M., showed the following: [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the required two step tuberculosis (TB-a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) screening test was administered timely, per facility policy, for one staff member. The facility census was 42. Record review of the facility's Infection Prevention and Control Policy, Tuberculosis Surveillance, undated, showed the following: -To prevent the spread of tuberculosis by completing tuberculosis testing on all employees; -All employees will have a two step TB testing with the first step being administered and read prior to starting to work. The second TB step will be administered within three weeks of the first step; -Employees will have annual testing thereafter; -There will be documentation completed for employees; [...]