Lakeside Post Acute

Inspectors wroteBased on record review and interviews, the facility failed to fully investigate and document incidents of sexual abuse involving one (#2) of one resident reviewed out of seven sample residents. Specifically, the facility failed to: -Conduct and document a thorough investigation of an allegation of sexual abuse involving Resident #2 as the victim of sexual abuse by staff members;-Interview the resident's roommate for what he might have heard or seen during the time of the alleged abuse incident;-Pursue the resident's ongoing allegations that staff were rough and abusive towards him during the provision of personal care; and, -Investigate why staff did not stop care when the resident made the allegation of abuse and have other staff take over care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#3) of four residents were kept free from physical abuse out of six sample residents. Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #4.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one (#1) of four residents out of eight sample residents received adequate supervision and facility-assisted devices to prevent elopement. Specifically, the facility failed to provide Resident #1 the supervision necessary to prevent elopements. These facility failures created a situation with the likelihood of serious harm to the resident's health and safety if not immediately corrected. Resident #1 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder (major mental illness), adult failure to thrive, cocaine dependence and alcohol dependence. A wander/elopement risk evaluation was completed upon the resident's admission on [DATE] and revealed Resident #1 had no previous elopement attempts and was not at risk for eloping or wandering. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were permitted to remain in the facility and not transfer or discharge for one (#1) of three residents reviewed for discharge planning out of eight sample residents. Specifically, the facility failed to provide Resident #1 with an appropriate discharge process.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from significant medication errors for two (#4 and #38) of seven residents reviewed for medication errors out of 32 sample residents. Resident #4, who had diagnoses of schizoaffective disorder (mental health condition that causes people to experience symptoms of schizophrenia and mood disorders) and bipolar, had a physician'sorder for clozapine (an antipsychotic medication). The medication required a complete blood count (CBC) laboratory result to be sent on a monthly basis to the pharmacy in order for the pharmacy to refill the medication. On 6/11/24, Resident #4 was administered her last available dose of clozapine, however, the results of the monthly CBC had not been obtained from the laboratory and faxed to the pharmacy in order for the pharmacy to refill the medication. [...]

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the facility's main kitchen and two out of four unit refrigerators. Specifically, the facility failed to: -Ensure beverages in the unit refrigerators were dated and labeled; -Ensure stacked pans were dried appropriately; -Ensure dented food cans were not used; and, -Ensure an appropriate test strip was used for the sanitizing bucket.

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 diseases and infection on two of four units. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touch areas (call lights, bed controls and light switches); -Ensure infection control protocols were followed during and after wound care provided to a resident in the facility's shower room; and, -Ensure staff performed hand hygiene appropriately during wound care.

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 the main entrance walkway was smooth without holes and gaps in the concrete surface; -Ensure the sidewalks and the common space areas were clear of debris, hoses and other equipment; -Ensure the residents had unrestricted access to hallway safety rails; -Ensure the common area recreational spaces were clear of extension cords; -Ensure the residents' hallway flooring was even without open gaps/spaces in the flooring surface; -Ensure the handicapped door opener was functioning and operational; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#8) of one resident reviewed out of 32 sample residents was provided personal privacy in her room. Specifically, the facility staff failed to knock before entering Resident #8's room while the resident was being provided with personal care.

Inspectors wroteBased on record review and interviews, the facility failed to develop and revise the comprehensive care plans that included the instructions needed to provide effective and person-centered care for one (#8) of four residents reviewed out of 32 sample residents. Specifically, the facility failed to ensure Resident #8's care plan was revised to address the resident's confrontational behaviors.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one (#19) of two residents reviewed for accident/hazards out of 32 sample residents remained as free from accident hazards as possible. Specifically, the facility failed to ensure Resident #19, who was an unsupervised smoker, smoked in an appropriate area designated for smoking.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#16) of one resident reviewed for dialysis care out of 32 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to consistently complete the pre-dialysis facility assessment section on dialysis communication forms for Resident #16.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#10) of three residents reviewed for ancillary services out of 32 sample residents received routine dental care and 24-hour emergency dental care. Specifically, the facility failed to ensure Resident #10 was provided dental services for new dentures timely.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure all drugs and biologicals were properly stored in one of two medication storage rooms and three of four medication carts. Specifically, the facility failed to: -Ensure out of date medications and treatment supplies were timely removed from the medication storage area; and, -Ensure liquid protein supplements were dated as to when they were first opened.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to ensure food items were stored and served under sanitary conditions. Specifically, the facility failed to ensure: -The snack/nourishment refrigerators on two of two units were maintained and open food items were dated, labeled, and discarded before the expiration date; and, -Opened containers of potentially hazardous foods or leftovers were dated and used within seven days or according to facility policy to prevent potential foodborne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Follow proper housekeeping and hand hygiene to prevent cross contamination; -Ensure two of three crash carts were cleaned of dust debris; and, -Ensure mechanical lifts were clean and sanitized after resident use.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for three (#8, #10 and #22) of five residents reviewed for vaccinations of 33 sample residents. Specifically, the facility failed to ensure Residents #8, #10 and #22 were offered and/or received either the influenza immunization and/or the pneumococcal immunization after consent was given.

Inspectors wroteBased on interview and record review the facility failed to protect two residents (#1 and #4) out of five residents out of 33 sample residents reviewed were free from abuse. Specifically, the facility failed to ensure Resident #1 was free from physical abuse by Resident #20 and Resident #4 was free physical abuse from from Resident #113.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary assistance with activities of daily living (ADLs) for one (#25) of three out of 33 sample residents to maintain personal hygiene. Specifically, the facility failed to provide assistance with showers to maintain personal hygiene and grooming for Resident #25, who was dependent for care.

Inspectors wroteBased on resident observation, record review and interviews, the facility failed to ensure one (#46) of three residents reviewed for pressure ulcers out of 27 total sample residents, received care consistent with professional standards of practice to prevent pressure injuries. Resident #46 was at high risk for developing pressure injuries due to being admitted to the facility with diagnoses of malaise (debility/lack of health), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left dominant side, and unspecified protein-calorie malnutrition. Resident #46 was admitted to the facility on [DATE] and was admitted with intact skin to both heels. [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a comprehensive care plan for two (#18 and #41) of five residents receiving anticoagulant medications out of 27 total sample residents. Specifically, the facility failed to develop and implement a care plan for anticoagulant medication use and develop interventions to monitor for signs/symptoms of bleeding due to the use of anticoagulant medication for Resident #18 and Resident #41.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper sanitation practices were followed in one of one kitchens to prevent food borne illness. Specifically the facility failed to: -Clean the walk-in cooler on a regular basis; -Ensure the fryer was cleaned according to the schedule; -Keep shelf above the stove free of grease and grime; and, -Ensure leftovers in the refrigerator were dated properly.