Lakeshore Post Acute and Rehabilitation Center

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident rooms, shower rooms and hallways received necessary maintenance and repairs.

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient discharge preparation and documentation for one (#97) of two residents reviewed for a safe and orderly discharge out of 55 sample residents. Specifically, the facility failed to notify the ombudsman in writing regarding Resident #97's discharge.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide ongoing group activities designed to support the needs and preferences of the residents for two (#2 and #78) of five residents reviewed for activities out of 55 sample residents. Specifically, the facility failed to provide activities that met Resident #2 and Resident #78's preferences.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of two residents received treatment and care in accordance with professional standards of practice out of 55 sample residents. Specifically, the facility failed to ensure timely follow-up from a telehealth (virtual) pulmonology appointment to ensure Resident #1 was evaluated through a sleep study for a potential continuous positive airway pressure (CPAP) machine.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide proper contracture management services, equipment, and assistance for two (#66 and #37) of three residents reviewed for restorative services out of 55 sample residents. Specifically the facility failed to:-Ensure staff consistently applied Resident #66's wrist splint to the resident's right hand, which had a contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff); and,-Ensure Resident #37 was provided with passive range of motion (PROM) to her bilateral ankles, which had contractures.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accident hazards for one (#5) of two residents out of 55 sample residents. Specifically, the facility failed to provide adequate supervision for Resident #5, who had a history of elopement.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%). Specifically, the facility's medication error rate was 10.3%, or three errors out of 29 opportunities for error.

Inspectors wroteBased on observation and interviews, the facility failed to ensure one (#99) of six residents out of 55 sample residents were free from significant medication errors. Specifically, the facility failed to ensure the insulin pen was primed in a manner consistent with professional standards of practice prior to medication administration for Resident #99.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of three medication carts and one of one medication storage rooms. Specifically, the facility failed to:-Ensure medications for discharged residents were stored in a secure manner; and,-Ensure residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one of six units. Specifically, the facility failed to:-Ensure Resident #99's glucometer was cleaned according to manufacturer recommendations; and,-Ensure proper hand hygiene was conducted during medication administration.

Inspectors wroteBased on record review and interviews the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for three (#3, #11 and #14) of four residents reviewed for baseline care plans out of 22 sample residents. Specifically, the facility failed to ensure pertinent medical information was included on Resident #3, Resident #11 and Resident #14's baseline care plans within 48 hours of admission.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three (#10, #6, and #4) of three residents reviewed for activities programming out of 22 sample residents. Specifically, the facility failed to offer and provide personalized activity programs for Resident #10, #6 and #4.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; and, -Beard restraints were worn in kitchen areas while serving food.

Inspectors wroteBased on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning resident care and dignity.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 14 of 60 resident rooms in six hallways. Specifically, the facility failed to ensure walls, baseboards and doors were properly maintained.

Inspectors wroteBased on record review and interviews, the facility failed to ensure five (#13, #38, #3, #23 and #52) of eight residents were free from unnecessary psychotropic medications out of 32 sample residents. Specifically, the facility failed to: -Monitor targeted behaviors and individualized non-pharmacological approaches for psychotropic medications for Residents #13, #38 and #3; -Follow pharmacist recommendations for gradual dose reductions of psychoactive medications for Resident #3 and #23; -Ensure risks were reviewed for an antipsychotic medication prior to administration for Resident #3; and, -Ensure as-needed (PRN) orders for psychotropic/antipsychotic medication did not extend 14 days without documented clinical rationale from the physician or a physician evaluation of the resident for Residents #52 and #23.

Inspectors wroteBased on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 for three of six units Specifically, the facility failed to ensure: -Staff performed hand hygiene between glove use; -Staff wore personal protective equipment (PPE) when entering COVID positive rooms; -Staff doffed (removed) gowns prior to exiting a COVID positive room; and, -A COVID positive resident did not occupy areas frequented by COVID negative residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNAs) consisted of annual training for dementia management for six of six CNAs reviewed. Specifically, the facility failed to ensure CNAs #3, #4, #5 #6, #1 and #2 received annual dementia management training. I. Training review Six nurse aides were reviewed for the annual required dementia management training. Training records revealed six of the six did not have the required annual training: CNA #3 was hired on 7/7/22. She had not had annual dementia management training. CNA #4 was hired on 1/21/21. She had not had annual dementia management training. CNA #5 was hired on 10/27/22. She had not had annual dementia management training. CNA #6 was hired on 8/31/21. She had not had annual dementia management training. CNA #1 was hired on 8/23/22. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (#31 and #55) out of four residents reviewed for abuse were kept free from abuse out of 32 sample residents. Specifically, the facility failed to: -Prevent a resident-to-resident altercations between Resident #58 and #55; and. -Prevent a resident-to-resident altercation between Resident #58 and #31.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of convenience, and the least restrictive alternatives were used for two (#52 and #11) of three residents reviewed for restraints out of 32 sample residents. Specifically, the facility failed to: -Obtain a physician's order for a lap buddy for Resident #52 and #11; -Obtain consent before the use of a lap buddy for Resident #52 and #11; and, -Evaluate the ongoing use of a lap buddy for Resident #52 and #11.

Inspectors wroteBased on interviews and record review, the facility failed to report alleged violations of potential abuse administration in accordance with State law involving one resident (#54) of four residents reviewed for abuse out of 32 sample residents. Specifically, a certified nurse aide failed to report verbal abuse immediately that she witnessed to facility administration by a nurse towards Resident #54. She documented it on a concern form and failed to take further action.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide services by qualified persons for one (#71) out of 32 sample residents. Specifically, the facility failed to ensure Residents #71 was assessed by a registered nurse (RN) following a fall.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide hearing assistive devices to residents for one (#22) of three residents reviewed for hearing devices out of 32 sample residents. Specifically, the facility failed to ensure the availability and education with staff on the use of hearing aides as ordered for Resident #22.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (#58) of three residents reviewed for accidents/hazards out of 32 sample residents. Specifically, the facility failed to ensure Resident #58 identified as a fall risk wore non-skid footwear while ambulating as identified in the care plan.

Inspectors wroteBased on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#183) of three residents reviewed for supplemental oxygen use out of 32 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Resident #183.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who were diagnosed with Alzheimer's/dementia received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for one (#58) out of four residents reviewed for mood and behavior out of 32 sample residents. Specifically, the facility failed to: -Develop a person centered individualized care plan with effective interventions for Resident #58; and, -Train staff on individualized person centered interventions for aggressive behaviors for Resident #58.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a call light was within the reach of one (Resident #40) of one sampled resident who was reviewed for accommodation of needs.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure notification of a facility-initiated transfer, including the reason for the transfer, was provided to the resident/representative for 1 (Resident #5) of 1 sampled resident reviewed for transfer notice requirements.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure a resident/resident representative was provided with information regarding the facility's bed-hold and reserve bed payment policy upon transfer to a hospital for 1 (Resident #5) of 1 sampled resident reviewed for transfer requirements.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to maintain a medication error rate of less than 5%. During medication administration observations, there were three medication errors out of 34 opportunities, which resulted in an 8.82% medication error rate for 2 (Resident #3 and Resident #13) of four residents observed during medication administration.