Lakeview Manor Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to have a system in place to provide individualized behavioral health services, which met the individualized needs of a resident by preventing and treating their mental health disorder(s) for 1 (#17) of 7 residents reviewed for behavioral health in the sample

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. Food was labeled and / or dated with a preparation date; and 2. Left over food was discarded in a timely manner. This deficient practice had the potential to affect any of the 91 residents who received nourishment from the facility's kitchen.

Inspectors wroteBased on record review and interviews, the facility failed to ensure nursing staff notified the provider when staff heard Resident #89 state she did not want to live anymore for 1 (#89) of 3 residents reviewed for Dementia Care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to respect the resident's right to personal privacy for 2 (#8 and #63) of the 25 residents reviewed for privacy in the initial pool. The facility failed to ensure Residents #8 and #63 had privacy curtains around their beds.

Inspectors wroteBased on interviews and record review the facility failed to ensure a resident with a newly identified psychiatric diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required for 1 (#51) of 4 sampled residents reviewed for PASRR. Review of the facility's undated Policy titled Resident Assessment- Coordination with PASRR Program revealed the following, in part: Policy: The facility coordinates assessments with preadmission screening and resident review (PASRR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident's comprehensive person-centered care plan was implemented by failing to administer enteral feeding as ordered for 1 (#53) of 2 (#53 and #71) residents reviewed with enteral feeding.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure each resident received services as outlined in the comprehensive care plan which met professional standards of quality for 1 (#53) of 2 (#53 and #71) residents reviewed with enteral feeding. The facility failed to ensure S6RN: 1. Verified Resident #53's physician orders prior to enteral feeding administration; and 2. Accurately documented administration of Resident #53's enteral feeding.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident received enteral feedings as ordered to maintain acceptable parameters of nutritional status for 1 (#53) of 4 (#37, #53, #65, and #71) residents reviewed for nutrition and/or enteral feeding.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Medication rooms were free of expired supplements for 1 (MR3) of 2 (MR2 and MR3) medication rooms reviewed; 2. Medication carts were free of expired supplements for 1 (MC3) of 2 (MC1 and MC3) medication carts reviewed; 3. Medication carts were free of loose pills for 1 (MC1) of 2 (MC1 and MC3) medication carts reviewed; and 4. Insulin pens were labeled with an opened date on 1 (MC1) of 2 (MC1 and MC3) medication carts reviewed. This deficient practice had the potential to affect all of the 97 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. food was dated after opening; 2. food was properly sealed and stored; and 3. staff with facial hair wore a beard restraint. This deficient practice had the potential to affect any of the 97 residents who received nourishment from the facility's kitchen.

Inspectors wroteBased on record reviews and interviews, the facility failed to report allegations of verbal abuse to the State Survey Agency immediately, but no later than 2 hours, for 1 (#195) of 3 (#5, #36 and #195) residents reviewed for abuse.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that each resident's comprehensive Minimum Data Set (MDS) assessments were completed in a timely manner for 1 (#195) of 5 (#9, #31, #65, #195, and #295) newly admitted residents reviewed for comprehensive assessments. The facility failed to ensure that the resident admission assessment was completed within the 14-day requirement.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident assessments accurately reflected the residents' status. The facility failed to ensure staff accurately coded: 1. The discharge status for 1 (#94) of 2 (#93 and #94) residents reviewed for discharge; and 2. The ostomy status for 1 (#22) of 2 (#22 and #81) residents reviewed for appliances.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the residents care plan was reviewed and revised for 1(#5) of 4 (#5, #12, #47, and #195) residents reviewed for accidents. The facility failed to update Resident #5's care plan when she exhibited new aggressive behaviors. This deficient practice had the potential to affect a current census of 96 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene by failing to ensure each resident received scheduled bed baths for 1 (#47) of 3 (#22, #45, and #47) residents reviewed for ADLs.

Inspectors wroteBased on observations, interviews and record review, the facility failed to implement effective fall interventions for 1 (#47) of 4 (#5, #12, #47, and #195) residents reviewed for accident hazards.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure S6RN had the specific competencies and skill sets necessary to care for residents' needs as identified in the plan of care. The facility failed to ensure S6RN was competent to: 1. Verify and administer enteral feedings as ordered by the Physician for 1 (#53) of 2 (#53 and #71) residents reviewed with enteral feeding; and 2. Identify Enhanced Barrier Precautions and don necessary PPE to provide care for 1 (#53) of 5 (#22, #53, #71, #81, and #195) residents reviewed on Enhanced Barrier Precautions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff utilized appropriate PPE during care with residents who required Enhanced Barrier Precautions for 1 (#53) of 5 (#22, #53, #71, #81, and #195) residents observed during chronic wound care and/or use of indwelling medical devices.

Inspectors wroteBased on record review and interviews, the facility failed to ensure nursing staff notified the resident representative when a resident had a significant change in condition for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to maintain complete and accurate records in accordance with accepted professional standards and practices for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. The facility failed to ensure nursing staff documented a resident's change in condition, provider notification of a resident's change in condition, and administration of Zofran.

Inspectors wroteBased on a record review, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) for 1(#2) resident who was on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident's assessment accurately reflected the residents' status. The facility failed to ensure: 1. A resident's Minimum Data Set yearly assessment was accurately coded in regards to PASRR Level II for 1 (#28) of 4 (#6, #15, #28, and #80) residents reviewed for PASRR; and 2. A resident's Minimum Data Set yearly and quarterly assessments accurately reflected the use of a bed alarm for 1 (#15) of 3 (#15, #56, and #59) residents reviewed for falls.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a record of the Level 1 Preadmission Screening Resident Review (PASRR) form was maintained in the resident's record for 1 (#6) of 4 (#6, #15, #28, and #80) residents reviewed for PASRR.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents received adequate supervision for 1 (#15) of 3 (#15, #56, and #59) residents reviewed for falls. The facility failed to ensure staff rounded on Resident #15 every 2 hours to prevent falls.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure S5CNA wore proper Personal Protective Equipment (PPE) while providing care for 1 (#42) of 8 (#21,#24, #33, #42, #61, #69, #193 and #194) residents on Enhanced Barrier Precautions (EBPs).