Lakeside Rehabilitation and Care Center

Inspectors wroteBased on record reviews, interviews, and policy review, the facility failed to develop the comprehensive care plan to include the use of an indwelling urinary catheter for one of 21 sampled residents (Resident (R)7) and include extreme pain with movement or touch for one of 21 sampled residents (R74) reviewed for care planning. This had the potential for the residents not to be monitored for an indwelling catheter, pain, and have unmet care needs.

Inspectors wroteBased on interviews, record review, and review of the facility's policy, the facility failed to ensure one resident (Resident (R) 28) was free from significant medication errors out of a total sample of 21 residents. The facility administered insulin to R28 when his blood sugar level was below the identified range to administer the insulin. The medication error had the potential to cause the resident to become hypoglycemic (abnormal decrease of sugar in the blood).

Inspectors wroteBased on observation, record review, policy review, review of the State Survey Long-Term Care Reporting Portal and interviews, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 6 of 8 residents (#4, #18, #20, 26, 46 and #56) reviewed for abuse and neglect. These deficient practices resulted in residents being subjected to neglect, abuse, and ongoing verbal abuse with the potential for physical and/or psychosocial harm.

Inspectors wroteBased on record review, review of the State Long-Term Care Reporting Portal, I&As, review of facility policies and procedure, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 4 of 4 residents (#3, #126, #127 and #129) reviewed for medication administration. Resident #129 was harmed when he experienced dizziness and low blood pressure and needed to be sent to the hospital due to his hypotension.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 69 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on review of facility policy, record review, document review, and interviews, the facility failed to ensure allegations of abuse were thoroghly investigated. This was true for 2 of 8 residents (#4, and #46) reviewed for abuse and neglect. This deficient practice created the potential for psychosocial, verbal, and physical harm whose abuse allegations were not investigated thoroughly, and measures taken to protect resident during the investigation, which placed all residents in the facility at risk of abuse.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 2 of 23 residents (#4, and #17) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to provide activities of daily living (ADL) care for 1 of 4 dependent residents (Resident #19) who required extensive assistance with personal hygiene/showers out of a total sample of 32 residents. This deficient practice created the potential for Resident #19 to have a decrease in their quality of life.

Inspectors wroteBased on observation, record review, policy review and staff interview, it was determined the facility failed to ensure resident-centered care were provided in accordance with professional standards of nursing practice and residents' comprehensive care plans. This was true for 3 of 23 residents (#4, #17, and #22) reviewed for quality of care. This deficient practice had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practice.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure residents received proper treatment to maintain foot health. This was true for 2 of 5 residents (#22 and #48) reviewed for foot care. This deficient practice created the potential for harm should residents experience complications related lack of proper foot care.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident with mental disorders received appropriate treatment and behavioral services. This was true for 1 of 1 resident (Resident #61) reviewed for mental and behavioral health care. This failure created the potential for the resident to experience compromised physical and psychosocial well-being.

Inspectors wroteBased on observation, policy review and staff interview, it was determined the facility failed to ensure medications were disposed properly. This was true for one of one staff (LPN #2) observed disposing the medications in the regular trash can. This deficient practice created the potential for harm if resident pick up and take the medication.

Inspectors wroteBased on observation, interview, review of facility policy, and review of facility training document, the facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for one of three residents (Resident #173) observed for enhanced barrier precautions (EBP) when providing care out of a total sample of 32 residents. This had the potential for the resident to have an increase for infection.

Inspectors wroteBased on policy review, review of grievances, and staff interview, it was determined the facility failed to ensure resident grievances were investigated and resolutions were documented. This deficient practice placed all residents at risk of having unmet needs and poor quality of life when their concerns were not properly addressed.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure licensed nurses were competent to administer insulin using a pen. This was true for 17 of 17 licensed nurses whose training records were reviewed for competencies. This had the potential to adversely affect residents who received insulin injections.

Inspectors wroteBased on observation, review of the FDA Food Code, and resident and staff interview, it was determined the facility failed to ensure resident meals were palatable and maintained their correct temperature. This directly impacted 2 of 2 residents (#10 and #41) and had the potential to affect the other 72 residents who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being.

Inspectors wroteBased on observation and interview, it was determined the facility failed to ensure food containers were appropriately labeled and free of spillage; food processing equipment was cleaned after use; and containers for dish storage were free of debris. This had the potential to affect 74 of the 74 residents who resided in the facility and consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, review of the Food and Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure trash was contained in the facility's dumpsters with closed lids for two of three outside trash dumpsters. This created the potential for insect and pest infestation.

Inspectors wroteBased on policy review, facility document review, and staff interview, it was determined the facility failed to ensure the Quality Assessment and Assurance (QAA) committee took actions to identify and resolve systemic problems. This failure affected 74 of 74 residents residing in the facility. The deficient practice resulted in insufficient monitoring and resolution of resident grievances which had the potential to cause residents psychosocial harm and/or decreased quality of life.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when hand hygiene was not performed during cares and food preparation. This directly impacted 1 of 4 residents (Resident #42) observed during resident care and had the potential to impact the other 70 residents residing in the facility. These failures had the potential to place residents at risk for cross contamination and infection.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure a resident was assessed periodically to determine if they were safe to self-administer medications for 1 of 1 resident (Resident #40) reviewed for self-administration of medications. This failure created the potential for adverse effects if Resident #40 self-administered medications inappropriately.

Inspectors wroteBased on policy review, observation, and staff interview, it was determined the facility failed to ensure residents' call lights were within reach for 2 of 2 residents (Resident #37 and #268) reviewed for residents' rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 1 of 21 residents (Resident #61) whose records were reviewed for advance directives. This deficient practice created the potential for harm or adverse outcomes if the residents' wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to report the results of investigations of potential abuse to the State Survey Agency within 5 days for 2 of 2 residents (#16, and #42) whose records were reviewed for abuse and neglect. This failure placed all residents in the facility at risk for abuse.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure all pertinent health information was provided to the receiving hospital for 3 of 4 residents (#28, #43, and #368) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to lack of information provided upon transfer.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 1 of 3 residents (Resident #43) reviewed for transfer. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to refer 2 of 3 residents (#42 and #61), who were admitted with a Level I Preadmission Screening and Resident Review (PASARR), to the appropriate state-designated authority for review after the resident was identified with a Major Mental Illness (MMI). This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to lack of updated screening.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of resident's admission. This was true for 1 of 1 (Resident #370) reviewed for baseline care plan. This failure created the potential for harm when the care plan failed to provide direction for care.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 1 of 21 residents (Resident #61) whose care plans were reviewed. This failure created the potential for residents to receive inappropriate or inadequate care with a potential for subsequent decline in mental/physical overall health.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure care plans were revised as needed with changes in resident status for 1 of 21 residents (Resident #37) whose care plans were reviewed. This deficient practice placed residents at risk for adverse outcomes if care and services were not provided appropriately due to a lack of information in the care plan.

Inspectors wroteBased on record review and resident and staff interview, it was determined the facility failed to ensure residents were provided with baths or showers consistent with their needs and preferences. This was true for 3 of 21 residents (#42, #51, and #64) who were reviewed for ADLs. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, and/or skin impairment and dental concerns due to a lack of personal hygiene.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of nursing practice were followed for bowel care and wound assessment. This was true for 2 of 21 residents (#43 and #56) whose records were reviewed. These failures created the potential for harm if residents experienced adverse effects with subsequent decline in health.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure catheter care was provided. This was true for 1 of 2 residents (Resident #66) reviewed for urinary catheters. This failed practice created the potential for residents to experience urinary tract infections (UTIs) due to lack of proper care.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 2 residents (Resident #63) reviewed for feeding tube use. This created the potential for harm if complications developed from improper tube feeding practices.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure non-pharmacologic interventions were offered or provided prior to administering as needed opioid pain medication. This was true for 1 of 1 (Resident #28) reviewed for pain management. This failure placed Resident #28 at risk of ADL decline related to unrelieved pain, and not being offered effective pain management.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident with mental disorders and history of trauma received appropriate treatment and services. This was true for 1 of 1 resident (Resident #61) reviewed for trauma-informed care. This failure created the potential for the resident to experience compromised physical and psychosocial well-being.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure actions were taken to address drug regimen reviews and recommendations identified by the consulting pharmacist were acted upon for 1 of 5 residents (Resident #7) reviewed for medication administration. This failure put Resident #7 at risk to experience adverse effects from medications that were not administered as recommended.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications were dated when opened and not expired. This was true for 2 of 2 medication storage rooms inspected. This failure created the potential for residents to receive expired medications with decreased efficacy.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure employees received training on abuse and neglect. This was true for 2 of 5 employees whose personnel records were reviewed. This failure had the potential for harm to all residents in the facility if an employee did not identify abuse and report accordingly.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the most recent survey results were accessible to residents, resident representatives, and visitors. This failure had the potential to impact all residents residing in the facility, their representatives, and visitors who wanted to review the facility's survey history.

Inspectors wroteBased on record review, review of the State Long-Term Care Reporting Portal, review of facility policies, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This affected 1 of 6 residents (Resident #1) reviewed for medication administration. Resident #1 was harmed when she did not receive 13 doses of short-acting insulin for 4 consecutive days and required hospitalization for emergency treatment for hyperglycemia.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to have an RN on duty for at least 8 consecutive hours a day. This was true for 11 of 28 days reviewed for RN coverage. This created the potential for harm if routine and/or emergency nursing services went unmet and had the potential to affect the 66 residents residing at the facility.