Lake Forest Senior Living at Mountain Home

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure an abuse policy was implemented and monitored that included a training program regarding abuse prevention required to be provided to staff, potentially affecting all residents that resided in the facility.

Inspectors wroteBased on facility record review, interviews, and policy review, the facility failed to ensure direct care staff were trained annually for Abuse/Neglect prevention and required in-service training for nurse aides, which potentially affected all residents that resided in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the kitchen and kitchen equipment were maintained in clean condition; and failed to ensure food items were sealed, labeled, and dated; The failed to ensure expired food and supplements were removed to prevent the potential for food borne illness; and the facility failed to ensure staff performed hand hygiene during meal service for 5 (Resident #3, 20, 24, 25 and 29) of 5 residents observed during the 11:30 AM meal service for infection prevention and control. This failed practice had the potential to affect all 32 residents that receive their meals from the facilities kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse coverage on 11-26-2023 on the 6:00 PM to 11:59 PM shift as evidenced by the shift report. The lack of coverage had the potential to affect all residents during the shift, that are dependent on the nurse for their care.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observations, interviews, record review, facility document review, and facility policy review the facility failed to ensure a resident received all doses of a physician ordered antibiotic for 1 (Resident #9) of 9 residents reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications and supplies were disposed of; and the facility failed to ensure medications and wound treatment supplies were stored and contained safely to prevent the accidental ingestion and or injury.

Inspectors wroteBased on observations, interviews, and facility policy review, it was determined the facility failed to ensure staff performed hand hygiene during meal service for 5 (Resident #3, 20, 24, 25 and 29) of 5 residents observed during the 11:30 AM meal service for infection prevention and control and failed to ensure staff donned appropriate PPE during resident medication administration for 1 (Resident #9) of 9 residents observed during medication administration. This failed practice had the potential to affect all residents in the facility who received meals from the dietary department and all residents receiving medication.

Inspectors wroteBased on record review and interview, the facility failed to assure a certified Infection Control Preventionist (ICP) was employed and available at least 20 hours a week, to establish and maintain the infection prevention program to help prevent the development and transmission of communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen equipment was clean and in good working order to prevent the spread of infection and food borne illnesses. This failed practice had the potential to affect 32 residents that receive their meals, from the facilities kitchen.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to revise a care plan for Resident #25 to include Ankle-foot orthosis (AFO)s to both lower legs to ensure the consistent use of braces to prevent decline in Range of Motion. A review of a facility policy titled, Care Plan- R/S, LTC, Therapy & Rehab dated 11-1-23, showed, Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical. functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments. the Resident Assessment Instrument (RAI) and review of the physician's orders . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure restorative therapy services were provided to decrease the potential for further decline in range of motion and maintain normal level of function for 1 (Resident #1) of 3 case mix residents. This failed practice had the potential to affect 5 residents who were receiving restorative therapy services according to the list provided by the Minimum Data Set Coordinator on 1/25/24 at 10:39 am.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items stored in the refrigerator, freezer, and dry storage areas were dated when received or opened and stored in sealed containers or packaging to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; spices were removed/discarded prior to losing their potency/flavor and stored in clean containers; and staff distributed and served meals and beverages in a food safe manner to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 22 residents who resided in the facility and received meals from 1 of 1 kitchen as documented on a list provided by the Administrator on 04/13/23 at 10:10 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure call lights were within reach to enable residents to call for assistance for 1 (Resident #8) of 15 (Residents #1, #3, #5, #7, #8, #10, #12, #15, #19, #21, #22, #23, #25, #129 and #130) sampled residents who can use a call light. This failed practice had the potential to affect 22 residents who can use a call light as documented on a list provided by the Administrator on 04/13/23 at 10:10 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy was provided to maintain dignity during wound care for 1 (Resident #20) of 1 sampled resident; failed to ensure medical information on laptops and computers was not visible to other staff, residents and/or visitors to prevent private medical information from being improperly divulged as evidenced by computer screens not being locked/logged out when not in use.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nail care was regularly provided to maintain good hygiene and prevent potential injuries or infections for 2 (Residents #12 and #21) of 15 (Residents #1, #3, #5, #7, #8, #10, #12, #15, #19, #21, #22, #23, #25, #129 and #130) sampled residents who required assistance with nail care. This failed practice had the potential to affect 22 residents who required staff assistance for nail care as documented on a list provided by the Administrator on 04/13/23 at 10:10 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure scissors, razors, clippers, and nail files were locked and stored properly to prevent the potential of accidents and injuries for 3 (Residents #12, #15 and #22) of 15 (Residents #1, #3, #5, #7, #8, #10, #12, #15, #19, #21, #22, #23, #25, #129 and #130) sampled residents. This failed practice had the potential to affect 22 residents who received medications stored by the facility as documented on a list provided by the Administrator on 04/13/23 at 10:10 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% was maintained to prevent potential complications for 1 (Resident #12) of 5 (Residents #5, #12, #15, #132, and #133 ) sampled residents observed during the observation of medication administration, resulting in medication errors. The Medication errors were made by Licensed Practical Nurse (LPN) #3, who was observed administering medications in the facility. The medication error rate was 8.0% based on the observation of 25 medication opportunities and 2 errors detected. This failed practice had the potential to affect 22 residents who received medications administered by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and beverages were covered while being transported to residents' rooms and while on kitchen counters awaiting meal service. This failed practice had the potential to affect 22 residents as documented on the list provided by the Administrator on 04/13/23 at 10:10 AM.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medications were accurately coded on the Minimum Data Set (MDS) for 1 (Resident #25) of 5 (Residents #1, #7, #10, #12, and #25) sampled residents whose MDS was reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing and cannulas were stored in an appropriate container to prevent potential contamination when not in use for 1 (Resident #12) of 4 (Residents #1, #12, #19 and #22) sampled residents who received respiratory therapy. The failed practice had the potential to affect 6 residents in the facility who received oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis fistulas and dressings were assessed immediately upon returning to the facility after receiving dialysis treatment for 1 (Resident #12) of 2 (Residents #1 and #12) sampled residents who received offsite Dialysis Services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medications were stored in a locked medication cart to prevent the potential accidental ingestion by other residents for 1 (Resident #22) of 15 (Residents #1, #3, #5, #7, #8, #10, #12, #15, #19, #21, #22, #23, #25, #129 and #130) sampled residents. This failed practice had the potential to affect 22 residents who received medications stored by the facility as documented on a list provided by the Administrator on 04/13/23 at 10:10 AM.