Lakefront Nursing & Rehab Ctr

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the outside dumpster's lid was closed in an effort to prevent pest migration. This failure has the potential to affect all 90 residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff don appropriate Personal Protective Equipment (PPE) while providing care to three residents (R10, R18, R343) in an Enhanced Barrier Precaution (EBP) room on the first floor and failed to decrease risk of cross contamination of linens in the laundry room. These failures have the potential to affect all 31 residents on the first floor and all 90 residents in the facility receiving laundry/linen services.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the code status for one resident (R73) was added to his medical chart. This failure has the potential to affect 90 residents that reside in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to obtain consent for the use of a psychotropic medication according to their policy for one (R1) of four residents, reviewed for unnecessary psychotropic medication regiment in the sample of 60 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one resident (R73's) wound treatment orders were entered per Physicians order. This failure has affected one of four residents reviewed for nursing care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow prescribed therapeutic diet order and failed to provide supplements for 2 of 4 residents reviewed for nutritional supplements. These failures affected two residents (R1, R38,) of four residents reviewed in the final sample of 60 residents. Findings Include: Face Sheet Documents R1 was admitted to the facility on [DATE] with the following diagnosis but not limited to Psychosis, Cannabis Abuse with Psychotic Disorder Generalized Anxiety Disorder, Mood Affective Disorder, Major Depressive Disorder, Personal history of COVID 19, Gastro-Esophageal Reflux Disease without Esophagitis, Vitamin D Deficiency, Hyperlipidemia, Constipation, Atherosclerotic Heart Disease, Hypertension. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to label and date opened multi-dose insulin Kwik pens for 2 residents (R34, R82), failed to date an eye drop for 1 resident (R57) and failed to discard an expired house stock. These failures affected three residents (R43, R57 and R82) and has the potential to affect all residents receiving medications from the second-floor medication cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure equipment used to puree food items was air dried prior to use in an effort to prevent food contamination. This failure has the potential to affect 2 (R21 and R59) residents on puree diet in the total sample of 60 residents.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide at least 80 square feet per resident in 6 multiple occupancy resident bedrooms. This affected 17 (R1, R2, R5, R15, R20, R22, R33, R34, R35, R47, R50, R55, R62, R72, R77, R81, R82) residents.

Inspectors wroteBased on interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R2) of seven residents reviewed for abuse. This failure resulted in R2 and R3 having a physical altercation, resulting in R2 bleeding from a scrape R2 sustained above the right eyebrow.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the plan of care to provide mechanically altered diet and nutritional supplements as ordered by physician for 1 (R1) of 4 residents reviewed for improper nursing care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure refrigerated food items were dated with a use by date, b.) discard expired and/or rotten foods, c.) follow manufacturer guidelines for storage, d.) keep food storage areas clean, e.) monitor chemical sanitizer concentrations of dish machine for dishware to be properly sanitized, f.) label and date dry storage items stored in bins, g.) clean ice machine and monitor for working order. These failures have the potential to affect all 94 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and serve mechanical soft food at the appropriate texture. This failure affected 8 (R8, R12, R16, R36, R42, R44, R58, R62) of 12 residents reviewed for mechanical soft diet prepared in the facility's kitchen, in a total sample of 19 residents. Findings Include: On 04/03/24 at 11:45 AM, during tray line observations observed V10 (Dietary Aide) calling out for a mechanical soft/ground diet order. Observed V23 (Cook) give V26 (Cook) slices of pork loin. V26 brought the slices of pork loin to a cutting board near the stove and began to chop the pork using a knife. V26 stated I'm helping to cut this food up for the mechanical soft diets. Observed the final chopped pork product to have no uniformity in size with larger and smaller pieces mixed together and the overall consistency appeared very dry. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure there are no more than 14 hours between the evening meal and breakfast the following day and failed to serve a substantial or nourishing snack at bedtime to residents who are not provided with an individualized evening snack. This deficient food service practice has the potential to affect 64 residents in a total sample size of 94 residents receiving an oral diet from the facilities kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to determine self-administration of medication was appropriate for 1 (R22) out of 12 residents reviewed for medication administration but allowed the resident to self-administer topical medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a timely person-centered care plan until after a resident experienced a forty-five-pound weight loss in less than 3 months from the date of admission. This failure affected 1 (R20) out of 4 residents who were reviewed for nutrition in the final sample of 19 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that smoking assessment/evaluation were completed on a quarterly basis. This failure could potentially affect 3 (R16, R78 and R85) of 5 residents reviewed for smoking in a total sample of 19.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow the dietary recommendations for residents who have weight loss for 3 (R45, R58, R66) out of 4 residents reviewed for nutrition in the final sample of 19 residents. Findings Include: 1.) On 4/02/24 at 12:22 PM, R45 was eating lunch in R45's room. R45's lunch tray consisted of one serving of noodles, one serving of fish, one serving of spinach, apple crisp, coffee, and juice. R45's meal ticket dated 4/2/24 does not indicate double portions. On 4/03/24 at 12:32 PM, R45 was eating lunch in R45's room and R45's lunch tray consisted of one piece of pork roast, one dinner roll, one scoop of mashed potato, juice, coffee, one serving of broccoli florets, and pudding. R45's meal ticket dated 4/3/24 does not indicate double portions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly discard multi dose insulin vial after 28 days of opening for 1 (R32) resident and properly date opened multi-dose nasal spray for 1 (R83) resident. The facility also failed to properly discard 2 expired house stock multi dose insulin pens from 2 of 3 medication carts and medication storage room inspected for medication storage and labeling.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide the required square footage of 80 square feet per resident for multiple resident bedrooms for 6 out of 48 rooms in the facility. Findings Include: On 4/2/24 at 9:25 AM, during the entrance conference with V1 (Administrator), V1 stated that the facility has multiple residents' rooms that are less than the required square footage per resident and that requires a variance. At 11:57 AM, V3 (Maintenance Director) stated that there are 6 residents' rooms in the facility that have waivers, and they are rooms 107, 108, 207, 208, 307, and 308. V3 stated that all 6 rooms have almost the same measurements. At 11:58 AM, there were 3 beds in room [ROOM NUMBER]. V3 measured the room and stated that the total area is approximately 226 square feet. At 12:01 PM, there were 3 beds in room [ROOM NUMBER]. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for one (R4) out of three residents reviewed for abuse. This incident resulted in one (R4) resident feeling emotionally and psychologically traumatized.

Inspectors wroteBased on interviews and review of records, facility failed to follow their policy to report allegation of abuse within required time frame for one (R4) out of three residents reviewed for abuse. The failure has the potential to affect one resident in addressing abuse incident.

Inspectors wroteBased on observations, interviews, and review of records, facility failed to follow their policy of completing quarterly fall risk assessments and failed to ensure resident has the right to be free from hazards, accident, and injuries for one (R1) out of three residents reviewed for hazards and accidents. This failure resulted in one resident (R1) sustaining multiple rib fractures.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a working wound vacuum and failed to assess one resident's (R85) wound. These failures affected one resident (R85) causing (R85's) wound to have a foul odor, purulent greenish drainage and (R85) feeling embarrassed due to the odor that permeated (R85's) room.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and rate pain for one resident (R73) that was experiencing a tooth ache and failed to administer pain medication as ordered. This failure resulted in R73 experiencing severe pain with facial grimacing and pain with eating. Findings Include: R73's admission record includes but not limited to diagnoses of schizoaffective disorder, atherosclerotic heart disease, chronic obstructive pulmonary disease, encephalopathy, hypertension, anxiety, and paranoid schizophrenia. R73's (2/21/23) Brief Interview of Mental Status documents a score of 15. (Cognitively intact). On 5/8/23 at 10:55 am surveyor observed R73 lying in bed with the covers pulled over R73's head. R73 pull the covers from over her head and surveyor observed R73 with facial grimacing when talking. R73 stated, My tooth hurts. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents' food items in the facility kitchen are properly labeled, dated when received and when opened, and a food package is securely sealed after opening. The facility failed to discard expired food items; failed to store drink items 6 inches off the floor; failed to ensure staff store their food and drinks out of the facility kitchen used for residents. The facility failed to maintain the proper sanitation levels of the kitchen sanitation buckets and the kitchen's low temperature dishwasher; failed to accurately test the sanitation level of the low temperature dishwasher; and failed to ensure that all kitchen staff were up to date with their food handler certifications. [...]

Inspectors wroteBased on observation, interview, and record review the facility staff failed to complete the controlled drug count sheet which is utilized to complete a shift-to-shift count for controlled substances. This failure has the potential to affect all 31 residents on the second floor and all 33 residents on the third floor.

Inspectors wroteBased on interview and record review, the facility failed to ensure that there was a physician's order for the code status in the resident's electronic medical record (EMR) which affected two residents (R40, R73) in a sample of 47 residents reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date oxygen equipment (oxygen tubing) per the facility policy. This failure affected one resident (R14) reviewed for oxygen equipment, in a total sample of 47 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide the required square footage of 80 square feet per resident for multiple resident bedrooms for 6 out of 48 rooms in the facility.