Lakeview Methodist Health Care Center

Inspectors wroteBased on observation and interviews the facility failed to ensure grievance forms were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously. This had the potential to affect all 66 residents in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a care plan was implemented to ensure activity preferences were identified and implemented for 1 of 2 residents (R31) reviewed for activities. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was admitted to the facility 10/16/25, had moderately impaired cognition, required partial to moderate assistance with transfers, and substantial/maximal assistance with shower/bathe and dressing, and required supervision with eating and oral hygiene. R1 identified it was somewhat important to do her favorite activities, keep up with the news, participate in religious services, go outside to get fresh air, have reading material, listen to music, and do things with groups of people. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure individualized activities were care planned and provided for 1 of 2 residents (R1) reviewed for activities.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide routine passive range of motion (PROM) on a consistent basis to improve strength, mobility and improve circulation for 1 of 1 resident (R32) reviewed for ROM. In addition, the facility failed to identify and develop interventions to reduce the risk of potential complications of a hand contracture.

Inspectors wroteBased on observation and interview, the facility failed to ensure basic infection control practices were followed when the tubing of a urinary drainage bag for 1 of 1 resident (R8), was observed laying on the floor of the shower. The deficient practice had the potential to cause infection.

Inspectors wroteBased on interview and document review, the facility failed to ensure documentation for 2 of 5 residents (R65 and R5) who refused influenza vaccine included education covering benefit and risk of the vaccine, and name and date of resident or representative who refused the vaccine

Inspectors wroteBased on interview and document review, the facility failed to ensure documentation for 1 of 5 residents (R65) who refused Covid-19 vaccine included education covering benefits and risks of the vaccine, and name and date of resident or representative who refused the vaccine.

Inspectors wroteBased on observation and interview, the facility failed to ensure beverageware was completely dry before storing, in order to prevent bacterial growth. This had the potential to affect all 29 residents who resided on second floor.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R264) reviewed who was observed to have medications at the bedside, had been appropriately assessed and deemed appropriate to self-administer medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 1 of 2 residents (R42) reviewed for elopement devices and 1 of 1 resident (R62) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a care plan was revised to address pressure ulcer risk and preventative measures for 1 of 2 residents (R31) reviewed for pressure ulcers (PU).

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess skin and/or consistently implement interventions to prevent the development of new pressure ulcers for 2 of 2 residents (R31, R48) who were reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R314) who was observed using an electric heating pad, was free of potential injury.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 resident (R36, R58) were administered the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 7 of 7 residents (R3, R12, R19, R24, R32, R41, R49) who voiced concerns with mail delivery during resident council. This deficient practice had the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow phsycician's orders per the standard of practice related to urostomy bag changes for 1 of 1 resident (R1) who had bilateral urostomies.

Inspectors wroteBased on observation and interview, the facility failed to identify and date facility-made frozen soups stored in 4 of 4 kitchenettes, and failed to ensure dishes in the kitchen were stored dry. This had the potential to affect all 61 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines to prevent the spread of Covid-19 when during a Covid-19 outbreak, failed to ensure appropriate use of personal protective equipment (PPE) when staff were observed not an wearing N-95 mask in the room of 1 of 1 resident (R51) in transmission based precautions (TBP) for Covid-19; failed to doff (remove) PPE per guidelines with staff were observed removing all PPE including N-95 masks prior to exiting the room of residents in TBP for Covid-19 for 4 of 4 residents (R51, R53, R29, R30); failed to ensure precautions posted on resident room doors (R51, R34, R29, R53, R211, R43, R22, R30, R159 and R160) were consistent and followed CDC recommendations; [...]

Inspectors wroteBased on observation, interview and document review the facility failed to provide a dignified dining experience for 1 of 1 residents (R17) who required assistance with dining.

Inspectors wroteBased on interview and document review, the facility failed to notify a provider of a significant physical change for 1 of 1 resident (R10) reviewed for notification of change.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide routine removal of facial hair for 1 of 1 resident (R17) and bathing for 1 of 1 (R30) resident reviewed for activities of daily living (ADLs) who were dependent on staff for cares.

Inspectors wroteBased on interview and document review, the facility failed to make an appointment for 1 of 1 resident (R44) reviewed for vision.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure weekly comprehensive skin assessments were completed for 1 of 3 residents (R27) reviewed for pressure ulcers

Inspectors wroteBased on observation, interview and document review, the facility failed to accurately assess and monitor ongoing safe smoking practices for 1 of 1 resident (R23) reviewed for smoking.

Inspectors wroteBased on interview and document review, the facility failed to comprehensively reassess and develop interventions to reduce/prevent continued weight loss for 1 of 1 resident (R7) reviewed for weight loss.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure oxygen tubing was changed and dated timely, and failed to create a comprehensive plan of care for oxygen therapy for 1 of 2 residents (R50) reviewed for respiratory care.