Lakeview Health Care & Rehabilitation Center

Inspectors wroteBased on interviews and record review, facility staff failed to ensure residents were given the right to make choices about aspects of their lives in the facility, when staff did not give one resident (Resident #1) the choice to refuse his/her medication. The facility census was 56.1. Review of the facility's Resident Rights policy, dated 02/2001, showed employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/16/26, showed staff assessed the resident as cognitively intact, rejects care daily, and received antipsychotic medication. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from restraint when the Director of Nursing (DON) used his/her body to restrain and prevent the freedom of movement for the resident to administer the resident's injectable medication. The facility census was 56. 1. Review of the facility's Use of Restraints policy, dated 2001, showed restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. [...]

Inspectors wroteBased on interviews, and record review facility staff failed to report an allegation of sexual abuse for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the required two hour timeframe. The facility's census was 52. Review of the facilities Abuse, Neglect, Exploitation and misappropriation prevention program, revised April 2021, showed the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment for residents when staff failed to attempt to minimize foul odors in the hallway and facility entrance, failed to repair wall damage and failed to repair wheelchairs. The facility census was 46.1. Review of the facility's Homelike Environment policy, dated February 2021, showed:-The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting to include: a clean sanitary and orderly environment, clean bed linens that are in good condition and pleasant, neutral scents;-The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting, to include, institutional odors. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure three residents (Resident #3, #42, and #45), who were unable to carry out activities of daily living (ADLs), received the necessary care and services to maintain personal hygiene out of eight sampled residents. The facility census was 46. 1. Review of the facility's ADL policy, dated April 2025, showed appropriate care and services are provided for residents who are unable to carry out ADL's, independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with bathing, dressing grooming and oral care) and toileting. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to reheat pureed food items in accordance with standardized recipes and failed to maintain the internal temperature of pureed food items placed on the steam table to prevent the growth of food-borne pathogens and potential for food-borne illness. The facility census was 46.1. Review of the facility's Cooking and Cooling policy, dated 2020, showed: -Foods will be cooked thoroughly, reaching the appropriate internal temperature specific to each item;-Length of cooking time and internal temperatures vary according to the type of food and temperatures must be reached and held for a specified amount of time;-A properly calibrated thermometer should be inserted into the thickest part of the food, and at least two readings should be taken in different places to ensure the proper temperature has been reached. [...]

Inspectors wroteBased on observation, and interview, facility staff failed to provide complaint investigation results in a prominent and publicly available space for investigations completed January 30, 25 to December 8, 25. The facility staff also failed to post the location to for the reports. The facility census was 46.1. Review of the facility's Survey Binder located at the nurse's station did not contain complaint investigation results or documentation for investigations completed for 01/30/25, 03/11/25, 3/31/25, 05/01/25, 05/06/25, 06/12/25, 07/01/25, 07/04/25, 08/12/25, 09/16/25, 10/2/25, 12/01/25, and 12/08/25.2. Observation on 01/05/26 at 10:15 A.M., showed the survey binder on the nurse's station. The binder did not contain investigation results or documentation for investigations completed since 01/15/25. The facility did not post the location to for the reports. 3. [...]

Inspectors wroteBased on interviews and record review, facility staff failed to report an allegation of physical abuse for one resident (Resident #1) to the Department of Health and Senior Services (DHSS) within the two-hour timeframe. The facility's census was 43. 1. Review of the facility's Abuse Investigation and Reporting policy, Revised July 2014, showed an alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of an unknown source and misappropriation of resident property) will be reported immediately, but no later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. Findings of abuse investigations will also be reported.2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to transcribe one resident (Resident #2) out of two sampled residents medication Omeprazole (used for heartburn) order from the hospital. The facility census was 43.1. Review of the facility's Administering Medications policy, dated 2001, showed staff are directed as follows:-Medications are administered in a safe and timely manner, and as prescribed;-The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication;-If a dosage is believed to be inappropriate or excessive for a resident, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to review and revise the comprehensive care plan for two residents (Resident #1 and #2) out of three sampled residents care plans who sustained falls. The facility census was 42. 1. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated 03/2022, showed assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's Falls policy, undated, showed falls can often be an indicator of an impending decline. Each fall must be followed up with and updated in the plan of care with new interventions. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to follow infection control practices and implement outbreak testing when two residents (Resident #1 and Resident #2) became symptomatic for Coronavirus Disease (COVID-19) . The facility census was 48. 1. Review of the facilty's COVID-19 - Testing Residents policy, undated, showed facility staff were directed to test residents with sign or symptoms of COVID-19 as soon as possible, regardless of vaccination status. Staff are directed residents and staff are tested for the SARS-CoV-2 virus to detect the presence of current infections (viral testing) and to help prevent the transmission of COVID-19 in the facility. [...]

Inspectors wroteAT Based on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility census was 35. 1. Review of the facility's Staffing, Sufficient and Competent Nursing Policy, undated, showed the facility provides sufficient numbers of nursing staff with appropriate skills and competency necessary to provide nursing and related care and services 24 hours a day, including a registered nurse for at least 8 consecutive hours daily, seven days a week. 2. Review of the facility's RN staff schedule, dated June 2024, showed the facility did not have an RN in the building on: -06/28/24; -06/29/24; -06/30/24. 3. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN in the building on: -07/04/24; -07/05/24; -07/06/24; -07/07/24; -07/08/24; [...]

Inspectors wroteReviewed-sk/at Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 35. 1. Review of the facility provided policies, showed the records did not contain a policy related to the qualifications for Director of Food and Nutrition Services. During an interview on 09/10/24 at 9:08 A.M., the dietary supervisor (DS) said he/she started in the dietary supervisor position about three months prior. The DS said he/she had taken food handler courses in the past but had never taken any type of food service manager courses. [...]

Inspectors wroteReviewed AT Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for one resident (Resident# 21), and failed to update care plans at least quarterly in conjunction with the required Minimum Data Set (MDS), a federally mandated assessment tool to be completed by staff, to provide current interventions to meet individual needs for four (Resident #15, #17, #20, and #30) out of 12 sampled residents. The facility's census was 35. 1. Review of the facility's Care Plans-Baseline Policy, dated March 2022, showed the baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than 21 days after admission). [...]

Inspectors wroteReviewed AT Based on observation, interview, and record review, facility staff failed to ensure residents' environment remained free of accident hazards when staff failed to ensure resident rooms were free of smoking materials for three unsupervised residents who smoke (Resident #16, #27 and #31) out of five sampled residents. The facility census was 35. 1. Review of the facility's Resident Smoking Policy, undated, showed independent smokers will be issued lockers with a lock and a key. Smoking materials may not be kept in resident rooms. 2. Review of Resident #16's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/14/24, showed staff assessed the resident as cognitively intact. Observation on 09/09/24 at 2:30 P.M., showed the resident had a half carton of cigarettes on the floor by the residents bed. [...]

Inspectors wroteAT Based on observation, interview, and record review, facility staff failed to maintain a medication error rate of less than 5% out of 42 opportunities observed, 21 errors occurred, resulting in a 50% error rate, which effected four residents (Resident #13, #14, #20, and #27) out of 11 sampled residents. The facility census was 35. 1. Review of the Facility's Administering Medication policy, revised April 2019, showed medications are administered in accordance with prescriber orders and the individual administering the medication checks the label three (3) times to verify the right dose before giving the medication. 2. Review of Resident #14's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/12/24, showed staff documented the resident diagnosis of gastroesophageal reflux disease ((GERD) acid indigestion). [...]

Inspectors wroteAT Based on interview and record review, facility staff failed to ensure the two-step purified protein derivative ((PPD) skin test for Tuberculosis (TB)) was completed in accordance with their policy and on file for four employees (Director of Nursing (DON)), Licensed Practical Nurse (LPN) A, Dietary B, and Minimum Data Set (MDS) coordinator) out of ten employee files reviewed. The facility census was 35. 1. Review of the Facility's Employee Screening for TB, revised March 2021, showed: -All employees are screened for latent tuberculosis (LTBI) and active TB disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment; -Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made but prior to the employee's duty assignment. [...]

Inspectors wroteReviewed AT Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends for three residents (Resident #2, #27, and #39) out of 12 sampled residents. The facility's census was 35. 1. Review of the facility's policy titled, Activity Programs, dated 06/2018, showed the activities program is provided to support the well-being of residents and to encourage both independence and community interaction. Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. 2. Review of the facility's Activity Calendar, dated July, 2024, showed: -Saturday, 07/06/24- Cards/Word Searches; -Sunday, 07/07/24- National Macaroni Day/Christmas Pajama Day; [...]

Inspectors wroteAT Based on observation, interview, and record review, facility staff failed to complete the required nurse staffing information to include the facility census. The facility census was 35. 1. Review of the facility's Posting Direct Care Daily Staffing Numbers policy, dated 08/2022, showed the information recorded on form shall include the resident census at the beginning of the shift for which the information is posted. Records of staffing information for each shift are kept for a minimum of eighteen months. 2. Review of facility's daily staffing sheets, dated August 2024, showed the sheets did not contain facility census on: -08/11/24; -08/12/24; -08/13/24; -08/14/24; -08/19/24; -08/24/24; -08/24/24; -08/25/24; -08/26/24; -08/27/24; -08/28/24. 3. Review of facility's daily staffing sheets, dated September 2024, showed the sheets did not contain facility census on the following dates: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide necessary treatment and services, consistent with professional standards of practice to prevent the development of pressure injuries and promote healing when staff failed to complete weekly wound assessments for one resident (Resident #1) of three sampled residents and failed to notify the physician when the resident's pressure injury worsened. The facility census was 45. 1. Review of the National Pressure Injury Advisory Panel's, Staging Definitions, dated 2016, showed Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain a clean, comfortable and homelike environment by failing to ensure resident areas were maintained clean, in good repair and free of odors. The facility census was 42. 1. Review of the facility's polices showed the facility staff did not provide a Housekeeping Policy or Facility Maintenance Policy. Review of the facility's Homelike Environment Policy, revised February 2021, showed: -Residents are provided with a safe, clean, comfortable and homelike environment; -The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include - pleasant, neutral scents; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete or update care plans and provide interventions to meet individual needs for three residents (Residents #5, #35 and #36) of five sampled. The facility's census was 42. 1. Review facility's care plan policy, revised March 2022, showed: The comprehensive, person-centered care plan: -describes the services that are to be furnished to attain or maintain the residents highest practical physical, mental, and psychosocial well-being; -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; [...]

Inspectors wroteBased on observation, interview, and record review the facility staff failed to follow professional standards when staff prepared 26 medication cups with medications prior to the timed medication pass. Additionally, the facility staff failed follow physician tube feeding orders, document the food consumption, and follow the diet order for one resident (Resident #36). The facility census was 42. 1. Review of the facility's Administering Medications policy, revised April 2019, showed: -Medications are administered in a safe and timely manner, and as prescribed; -The director of nursing services supervises and directs all personnel who administer medications and/or have related functions; -Medication administration times are determined by resident needs and benefit, not staff convenience; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when they failed to properly propel four residents (Resident's #13, #21, #27, and #32) in wheelchairs in a manner to prevent accidents. The facility census was 42. 1. Review of the facility's policies showed staff did not provide a Wheelchair Safety Policy. 2. Review of Resident #13's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/27/23, showed staff assessed resident as: -Cognitively intact; -Required no assistance for locomotion on and off the unit; -Wheelchair and walker used as a mobility device. Observation on 06/21/23 at 02:12 P.M., showed the intermediate activities director propelled the resident in his/her wheelchair without foot pedals. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to complete side rail assessments, entrapment assessments, obtain a physician's orders, obtain a signed consent and update care plans for six residents (Resident #2, #3, #9, #35, #36, and #39) who utilized side rails. The facility census was 42. 1. Review of the facility's Bed Safety and Bed Rails policy, revised August 2022, showed: Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for us of bed rails have been met; -The residents sleeping environment is evaluated by the interdisciplinary team; -Consideration is given to the residents safety, medical conditions, comfort and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment; [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to store medications in a safe and effective manner for three sampled medication carts. The facility census was 42. 1. Review of the facility's Storage of Medications policy, revised November 2020, showed staff are directed as follows: - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. -Drugs and biological's are stored in the packaging, containers or other dispensing systems in which they are received. -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 2. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility staff failed to maintain kitchen equipment, walls, and floors in a clean and sanitary manner to prevent to the growth of bacteria and potential harborage of pests, to ensure freezer temperatures were zero degrees (°) Fahrenheit (F) or lower, and to store food in a manner to prevent cross-contamination and outdated use. This failure had the potential to affect all facility residents. The census was 42. 1. Review of the facility's [NAME] Cleaning Schedule, dated May 2023, showed: - AM [NAME] to clean steam table, toaster, food preparation table, sweep, and mop; - PM cook to clean steam table, toaster, food preparation table, sweep, and mop; - Staff initialed the cleaning schedule to show all items cleaned on both shifts 5/1/23 through 5/19/23; - Staff initialed the cleaning schedule to show all items cleaned on only the P.M. [...]

Inspectors wroteBased on observation and interview, facility staff failed to use appropriate infection control procedures to prevent or reduce the risk of spreading bacteria, when staff failed to wash or sanitize their hands in between glove changes during perineal care, wiped multiple times with the same area of the wipe for one resident (Resident #2), and failed to ensure the two-step purified protein derivative (PPD) (skin test for TB) was completed in accordance with their policy and on file for four employees (CNA A, Dietary Aide B, Dietary Aide C and the Social Serviced Director) out of ten employee files reviewed. The facility census was 42. 1. Review of the facility's Handwashing/Hand Hygiene policy, revised August 2019, directed staff to: -All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to offer, administer, and document the administration or refusal of the influenza and/or the pneumococcal immunization for six of six residents (Resident #15, #27, #31, #36, #37, and #344) sampled. The facility census was 42. 1. Review of the facility's Pneumococcal Vaccine policy, revised October 2019, showed the following: -All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections; -Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series unless medically contraindicated or the resident has already been vaccinated; -If refused, appropriate entries will be documented in each resident's medical record indicating the date of refusal of the pneumococcal vaccination; [...]

Inspectors wroteBased on interview and record review facility staff failed to provide documentation of assessments, monitoring and ongoing communication with the dialysis (a clinical purification of blood as a substitute for the normal function of the kidney) center, and failed to obtain a physician's order for one (Resident #47) resident who received dialysis. The facility census was 42. 1. Review of the facility's Hemodialysis Catheters- Access and Care of Policy, dated February 2023 showed the following: -Dialysis catheters should be marked for dialysis use only so they are not confused with central venous access devices; -The site may not be used for dialysis until a written order is received from the nephrologist or surgeon; -Care involves the primary goals of preventing infection and maintaining patency of the catheter; -Keep the access site clean at all times; [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure two Nurse Aides (NA) (NA J and NA K) of four NAs sampled, completed the nurse aide training program within four months of their employment in the facility. The facility census was 42. 1. Review of the facility's Nurse Aide Qualifications and Training Requirements, dated August 2022, showed the facility showed the following: -The facility will not employ any individual as a nurse aide for more than four (4) months full-time, temporary, per diem, or otherwise, unless: --That individual is competent to provide designated nursing care and nursing related services; and --That individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or that individual has been deemed competent as provided in. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration agreement was explained to the resident and/or to his/her representative in a form and manner that he/she understood for one resident (Resident #47). The census was 42. 1. Review of the facility's policies showed staff did not provide a policy for arbitration agreements. Review of the Resident's #47's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/7/23 showed the resident was cognitively intact. Review of the Resident and Facility Arbitration Agreement, dated 6/8/23 showed the resident signed to allow arbitration. During an interview on 6/22/23 at 9:59 A.M., the resident said he/she did not remember signing or agreeing to the arbitration agreement. [...]

Inspectors wroteBased on observation and interview, the facility failed to post, in a form and manner accessible to the residents and resident representatives the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SSA). The census was 42. 1. Review of the facility's policies showed staff did not provide a policy on required postings. Observations from 6/20/23 through 6/23/23 showed the facility did not post the name, address and toll free telephone number for the Elder Abuse Hotline in an accessible manner for residents or resident representatives. During an interview on 6/23/23 at 2:54 P.M., District Housekeeping Manager said the toll free abuse and neglect hotline should be posted at up at the front entrance to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the most recent survey results were posted and readily accessible to residents, family member or representatives of residents. This has the potential to affect all residents in the facility. The facility census was 42. 1. Review of the facility's Survey Results Policy, revised April 2007, showed a copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room. Observation on 6/20/23 at 10:00 A.M. [...]