Lakeland Village Nursing Facility

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident remained free from verbal and physical abuse for 1 of 3 sample residents (Resident 1). This failure placed the residents at risk for physical and psychological harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement interventions to prevent a resident from ingesting an exam glove for 1 of 3 residents (Resident 1) reviewed for accidents and supervision. This failure placed residents at risk for medical complications and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice to prevent a medication error for 1 of 5 sampled residents (11), reviewed for unnecessary medications. Specifically, Resident 11 received a dose of an antibiotic that was on their list of allergies. This failure placed the resident at risk for health complications and possible anaphylaxis (a serious and potentially fatal allergic reaction).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain respiratory equipment in a clean manner for 2 of 3 sampled residents (Residents 1 and 69) reviewed for respiratory care. This failure placed the residents at risk for illness and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene when indicated during 1 of 4 medication administration observations. Additionally, the facility failed to ensure PPE (personal protective equipment, gowns and gloves) and incontinence pads were disposed of properly and a hoyer lift (a lift used to transfer residents) was sanitized between resident transfers to prevent the spread of bacteria.

Inspectors wroteBased on observation and interview, the facility failed to ensure chemicals and tools were secured in 2 of 3 rooms observed and 1 of 1 supply cabinets. In addition, the facility failed to ensure wheelchairs, seatbelts and foot troughs (a device used to hold a resident's lower extremities in place) were maintained in a clean manner for three residents (Residents 1, 10, 69), a fan for one resident (Resident 1) and a tube feeding pole for one resident (Resident 69) reviewed for physical environment. In addition, the facility failed to maintain clean refrigerators and a freezer on 1 of 6 cottages. This failure placed residents at risk of potentially avoidable accidents, lack of dignity and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from neglect for 1 of 3 residents (Resident 2). The failure to provide medical care, as ordered by the facility medical provider, resulted in a possible diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely reporting of an allegation of neglect for 1 of 1 resident (Resident 1). This failure resulted in potential harm and decreased quality of life for the resident.

Inspectors wroteBased on interviews and record review the facility failed to protect 2 of 5 sampled residents (Resident 1, 2) from abuse. These failures resulted in the potential for physical and psychological harm, and decreased quality of life for all residents.

Inspectors wroteBased on interview and record review the facility failed to meet professional standards of practice in provision of providing timely incontinence care for 2 of 3 sampled residents (Resident 1 and 2). This failure placed residents' requiring incontinence care at risk for potential skin injury and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to test modified fluid consistencies after preparation and before serving to vulnerableresidents at risk for aspiration (inhalation of food, liquid, or other material into the airway or lungs) in accordance with professional standards of practice and resident needs for 3 of 9 sampled residents (Residents 8, 30 and 43), reviewed for food and nutrition services. In addition, the facility failed to ensure that foods were stored and prepared in a safe manner, and dishwasher temperatures met the required standard which placed residents at risk for food borne illness and diminished quality of life for all 75 residents. The failure if the facility to make sure that residents at risk of aspiration received the correct fluid consistency represented an immediate jeopardy (IJ). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to review policies yearly as required, perform hand hygiene and/or glove changes when indicated, handle, store, and transport laundry in a manner to prevent the spread of infection. In addition, the facility failed to place signage in a conspicuous location outside the residents' room to clearly identify transmission based precautions implemented and appropriate personal protective equipment (PPE) to be used, and implement enhanced barrier precautions to prevent the spread of multidrug-resistant organisms (MDROs) for 1 of 3 sampled residents (Resident 14), reviewed for infection control. This failure placed residents at risk of development of a MDROs, communicable diseases, and diminished quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure all staff had food handler's cards (a certification that showed staff had completed training on food safety) to prepare food for facility residents. Specifically, in 6 of 7 cottages, the staff were occasionally preparing and cooking some foods, without food handler's cards. In addition, 1 of 24 dietary staff (C) had an expired food handler's card. This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 sampled residents (72), reviewed for unnecessary medications, was informed of the potential risks associated with the use of psychotropic medications (medications that can affect the mind, emotions, and behaviors). This failure placed the resident and/or their representative at risk of not being fully informed of the potential risks and benefits of taking the medications.

Inspectors wroteBased on interview and record review the facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for 2 of 3 sampled residents (Residents 12 and 60), reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent and heal pressure ulcer/injury for 1 of 1 sampled resident (Resident32). This failure placed other residents at risk for development of pressure ulcers, medical complications, and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of potential abuse were reported immediately to the State Agency as required, for 1 of 3 sampled residents (Resident 1) reviewed for abuse. This failure placed residents at risk for possible abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect, assess and monitor 1 of 3 sampled residents (Resident 1) after an allegation of verbal abuse. Failure to immediately protect the resident, failure to immediately assess the resident and failure to start monitoring for any potential harm related to the abuse allegation, placed residents at risk for diminished quality of life, and continued possible abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 5 residents (Resident 1) reviewed for abuse and/or neglect. The failure to provide incontinence care to a resident who was identified to be incontinent of bladder and required staff assistance for toileting, as well as the failure to provide an adequate morning meal resulted in emotional distress and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of potential abuse and/or neglect were reported immediately to the State Survey Agency, as required, for 1 of 5 sample residents (Resident 1). This failure placed residents at risk for abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation into allegations of neglect in a timely manner, for 2 of 5 sample residents (Resident 1 and 2). Failure to recognize allegations as possible neglect, failure to protect the residents and failure to immediately investigate allegations, placed residents at risk for diminished quality of life, and continued possible neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of potential abuse were reported immediately to administration and the State Agency as required, for 2 of 3 sampled residents (1 and 2) reviewed for abuse. This failure placed residents at risk for possible abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure cleaning supplies were used per manufacturer recommendations in the 3-compartment sink in the main kitchen and on the main kitchen food preparation surfaces, and in 5 of 7 (Harvest, [NAME], Ponderosa, Tamarack and Shamrock) resident cottage kitchen areas inspected. This failure placed residents at risk for food-borne illnesses and potential contamination of food items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supervision and safety devices were in place for 1 of 5 sample residents (20), reviewed for falls. This failure placed the resident at risk for falls and serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve foods and food groups as directed by the menu for 1 of 2 sample residents (14), reviewed for nutrition. This failure caused the resident to receive less food than what the menu indicated, and placed the resident at risk for unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the sanitizer dispenser for 1 of 1 three-compartment sinks inspected in the kitchen was repaired timely. This failure placed residents at risk of food-borne illnesses.