Lakeview Extended Care and Rehabilitation

Inspectors wroteThis citation pertains to Intake Number 3008221. Based on observation, interview and record review, the facility failed to ensure the accurate dispensing of medication, as ordered, for one resident (Resident #1) of three residents reviewed for medication administration.

Inspectors wroteThis citation pertains to intake Number 2701247. Based on observation, interview and record review, the facility failed to ensure that the medication storage room was locked and secured.

Inspectors wroteBased on observation, interview and record review the facility failed to provide appropriate treatment and services for an indwelling catheter for three residents (R3, R4, R19) of three residents reviewed for indwelling catheters, resulting in leaky catheter tubing, catheter tubing touching the floor and urine collection bags being uncovered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary and homelike environment in the residents' bathroom and communal shower room, for four residents (#9, #13, #15, #16), and residents that use the shower room), of five residents reviewed for homelike environment, resulting in the potential for embarrassment, dissatisfaction of living conditions, and spread of infection. ]

Inspectors wroteBased on interview and record review the facility failed to ensure that physicians' orders for code status was present in the EMR (electronic medical record) for three residents (R15, R19 and R21) of four residents reviewed for advance directives, resulting in the absence of code status orders in the EMR and the potential for the resident's preference for life sustaining treatment to not be followed by the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for two residents (Resident #6 and Resident #25), of 12 residents reviewed for care planning, resulting in the potential for unmet care needs and a decline in overall health and wellbeing.

Inspectors wroteBased on interview and record review the facility failed to notify the physician of an unintended significant weight loss for one resident (Resident #17) of three residents reviewed for nutrition, resulting in a lack of physician oversight and potential interventions for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses (RN-Registered Nurses, and LPN-Licensed Practical Nurses) and Certified Nursing Assistants (CNA) received yearly competencies and/or education/in-services for 4 of 12 staff reviewed for education and yearly competencies/education, resulting in the potential for nursing staff to lack the necessary qualifications and training to adequately care for the needs of all residents residing at the facility and according to the facility assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a timely Preadmission Screening/Annual Resident Review (PASARR) for a comprehensive level II OBRA evaluation was completed for one resident (Resident #14) of one resident reviewed for PASARR review, resulting in the potential for delayed mental health services and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that care plans were evaluated, revised and/or updated for two residents (Resident #15 and Resident #17), of 14 residents reviewed for care planning, resulting in the lack of care plan revision and implementation of appropriate interventions and the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services were provided to one resident (Resident #25), of one resident reviewed for Hospice services and end-of-life care, resulting in a lack of coordination of comprehensive services and care provided to the resident and the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that drug regimen review recommendations were reviewed by the physician in a timely manner for one resident (Resident #21) of five residents reviewed for medications, resulting in the potential for the resident to receive unnecessary medications with potential adverse effects. Findings Include: Resident #21: Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record Review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #21 was admitted to the facility on [DATE] with diagnoses: diabetes, diabetic wound right great toe non/healing, chronic kidney disease, hypertension, peripheral vascular disease, gout, arthritis, anemia, sepsis, osteomyelitis (bone infection). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly secure a medication cart with medical supplies and prescription medications for the Long Hall medication cart, resulting in the medication cart left unlocked and not under direct supervision of the Nurse with the potential for drug diversion and ingestion of prescription medications.

Inspectors wroteBased on interview and record review, the facility failed to follow evidence-based practices for Infection Control, including : 1) That Infection Prevention and Control Program (IPCP) policies were reviewed annually, and 2) That surveillance for infectious illnesses was analyzed for identification of infections, communicable diseases, trends, patterns, and reported routinely, resulting in the potential for a lack of guidance to ensure compliance with infection control standards and exposure to infectious organisms, which could lead to an unidentified outbreak. Findings Include: FACILITY Infection Control On 10/25/23 at 11:07 AM, during a review of the Infection Prevention and Control Program (IPCP) with Infection Preventionist/IP Q, the facilities Infection Control policies were reviewed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct inspection of bed assist bars to monitor securement, bed safety and risk for entrapment for one resident (Resident #2) of two residents reviewed for bed assist bar safety, resulting the potential of injury and entrapment.