Lakeview Nursing Center

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure oxygen cautionary signage was posted on a resident's door for one (1) of 20 sampled residents (Resident #59).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure medications were stored securely and in accordance with professional standards of practice by allowing a resident to have medications stored at the bedside without an assessment for safe self-administration, for one (1) of 20 sampled residents. Resident #86Findings include:A review of the facility's policy, Resident Self-Administration of Medication, dated 8/2024, revealed, .Policy Explanation and Compliance Guidelines.7. Bedside medication storage is permitted only when it does not present a risk to confused residents. The following conditions are met for bedside storage to occur- a. The manner of storage prevents access by other residents.8. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide residents with an alternative meal choice of equal nutritive value for one (1) of 22 sampled residents (Resident #62).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to a clean, comfortable, homelike environment for two (2) of four (4) days of survey.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement a care-planned intervention related to falls for one (1) of eighteen (18) sampled residents. Resident #13.

Inspectors wroteBased on record review and interview, the facility failed to accurately report staffing data to the Centers for Medicare and Medicaid Services (CMS) using payroll and other verifiable sources in a uniform format, for one (1) of four (4) quarters reviewed, resulting in the facility triggering for excessively low weekend staffing, no Registered Nurse (RN) hours, and no licensed nursing coverage 24 hours/day.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to complete a Change in Status Form to generate a request for a Preadmission Screening and Resident Review (PASRR) Level Two (II) Assessment, for a resident with a mental status change, for one (1) of 18 residents reviewed for PASRR. Resident #37.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the resident environment remained free of accident hazards when a fall mat intended to prevent injury during falls was not properly placed for one (1) of three (3) residents reviewed for accidents/hazards, Resident #13.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to store food using sanitary methods to prevent cross-contamination, as evidenced by a plastic cup used as a scoop stored directly inside a container of cornmeal for one (1) of four (4) days of kitchen observations.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to maintain a clean environment and implement comprehensive care plan interventions during an annual recertification survey on 7/20/2023 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for two (2) of eight (8) deficiencies cited. F584 and F656. Findings Include: [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure timely administration of pneumonia vaccinations for one (1) of five (5) residents reviewed for immunizations (Residents #70).

Inspectors wroteBased on observation, interviews and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection, for one (1) of four (4) observations of staff entering and exiting residents' rooms.

Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to implement care plan approaches related to prohibiting the use of oxygen in the smoking area for one (1) of four (4) sampled resident's care plans. Resident #1. Findings Include: Record review of the facility's Comprehensive Care Plans policy date implemented 4/3/20, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . A record review of the Care Plan with a problem onset date of 11/6/23 revealed Problem/Need: SMOKING I am a smoker and requires supervision .Approaches .Supervise all smoking .Prohibition of oxygen use in the smoking area . [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide a safe smoking environment when the facility staff did not remove an oxygen (O2) canister from Resident #1 prior to entering the smoking area and did not secure a cigarette lighter to prevent Resident #1 from lighting a cigarette. This failure resulted in Resident #1 receiving burns to his face. This was for one (1) of three (3) sampled residents reviewed for smoking. Findings Include: Review of the facility's policy, Accidents and Supervision, dated 12/9/2020, revealed, Policy: The resident environment will remain as free of accident hazards as is possible .This includes .3. Implementing interventions to reduce hazard(s) and risk(s) . Policy Explanation and Compliance Guidelines .3. Implementation of Interventions .i. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to provide a privacy bag for a resident with an indwelling catheter for one (1) of five (5) residents with urinary catheters. Resident #235. Findings Include: Record review of the facility's policy titled Catheter Care, undated, revealed Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation .2. Privacy bags will be available and catheter drainage bag will be covered at all times while in use . On 07/17/2023 at 11:00 AM, during an observation, Resident #235 was lying in bed and had an indwelling catheter drainage bag that had yellow urine visible from the doorway and hallway. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to maintain a clean environment for two (2) of 20 resident rooms. Resident #54 and Resident #76 Findings Include: Review of the facility's policy, Routine Cleaning and Disinfection, dated 5/12/23, revealed, Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment .Policy Explanation and Compliance Guidelines .13. Cleaning of walls .will be conducted when visibly soiled. 14. Privacy curtains in resident rooms will be changed when visibly dirty . Resident #54 On 7/17/23 at 12:20 PM, in an observation and interview with Resident #54, the privacy curtain facing the resident had large visible stains and was soiled. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan related to a medication for one (1) of (20) care plans reviewed. Resident #54 Findings Include: Review of the facility's policy, Comprehensive Care Plans, undated, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Policy Explanation and Compliance Guidelines .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . In an observation and interview on 7/17/23 at 12:20 PM, with Resident #54 he was lying in the bed and there was a container of medication on his overbed table in front of him. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to provide nail care for a resident who was unable to carry out Activities of Daily Living (ADLs) for one (1) of (20) sampled residents. Resident #76.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident had been assessed for safe self-administration of medication and failed to ensure a physician's order was transcribed accurately for one (1) of (20) sampled residents. Resident #54 Findings Include: Record review of the facility's policy, Resident Self-Administration of Medication dated 6/23/2023, revealed, Policy .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely . Record review of the facility's policy, Medication Orders, undated, revealed, .Policy Explanation and Compliance Guidelines . 4. Documentation of Medication Orders .f. Transcribe newly prescribed medications on the .treatment record . [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure cautionary signage was posted related to oxygen usage for one (1) of one (1) resident reviewed for respiratory conditions. Resident #26 Findings Include: Review of the facility's policy, Oxygen Administration, dated 6/23/23, revealed, .Policy Explanation and Compliance Guidelines .6. Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use . On 07/17/23 at 11:12 AM, Resident #26 was sitting in a wheelchair next to his bed. There was an oxygen (O2) concentrator in the corner of the room, with a nasal cannula stored on the back of the concentrator. Resident #26 was not wearing the nasal cannula and was unable to communicate if he had removed the cannula himself. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to properly secure a medication for one (1) of (20) sampled residents. Resident #54 Findings Include: Review of the facility's policy, Medication Storage, reviewed/revised 6/20/23, revealed, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the .medication rooms .Policy Explanation and Compliance Guidelines 1. General Guidelines a. All drugs and biologicals will be stored in locked compartments . Review of the facility's policy, Resident Self-Administration of Medication, dated 6/23/23, revealed, .Policy Explanation and Compliance Guidelines .7. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage . [...]

Inspectors wroteBased on staff interviews and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to ensure the program was sustained and interventions were monitored for effectiveness for one (1) repeated deficiency related to Physician Order transcription errors that was cited in May 2022 and October 2022. The facility's continued failure during three surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee for three (3) of (3) previous surveys reviewed. Findings Include: Record review of the facility's policy, Quality Assurance Performance Improvement, dated 2/24/2021, revealed, Policy: It is the policy of this facility to .maintain an effective .QAPI program . During this recertification survey, the facility was cited F684 (Quality of Care). [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide written notification to the resident and the resident's representative, in a language they could understand, the reason a resident was transferred to the hospital for one (1) of one (1) resident records reviewed for hospitalizations.