Lakeview Village

Inspectors wroteBased on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident (R) 143 and his representative were provided with a bed hold policy that included the facility's per diem rate to hold a bed.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to update the plan of care for activity of daily living (ADL) assistance for Resident (R) 3.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide activity of daily living (ADL) assistance for Resident (R) 3 when staff failed to ensure she received fingernail hygiene care.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure staff implemented the interventions to promote wound healing for Resident (R) 11 when staff failed to use the foot cradle and Prevalon boots.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards for Resident (R)37 who required supplemental oxygen continuously and had the oxygen concentrator (a medical device that filters surrounding air to deliver concentrated oxygen) set-up in his bathroom with approximately 30 feet of oxygen tubing strung throughout his room, and R146 who required staff assistance when ambulating and ambulated throughout his room without staff present.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide Resident (R)148's physician ordered medications due to lack of availability.

Inspectors wroteBased on observation, interview, and record review, the facility failed to display accurate and identifiable posted nurse staffing information.

Inspectors wroteThe facility identified a census of 128 residents. The sample included three residents, with three residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). Based on observations, record review, and interviews, the facility failed to ensure staff provided adequate supervision to prevent an elopement for Resident (R) 1 and further failed to provide a thorough search in response to a WanderGuard (sensors that monitor doors and a technology platform that sends safety alerts in real-time) alert. On 04/13/25 at 07:15 PM, R1 who was severely cognitively impaired and at high risk for elopement, set off the WanderGuard alert system. Staff responded to the alarm 36 seconds later but did not see R1. [...]

Inspectors wroteThe facility identified a census of 116 residents. The facility had one main kitchen and two kitchenettes with dining areas. Based on observation, record review, and interview, the facility failed to ensure that staff stored and prepared food items in accordance with the professional standards for food service safety. This deficient practice placed the residents at risk for foodborne illnesses.

Inspectors wroteThe facility identified a census of 116 residents. The sample included 24 residents. Based on observation, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to the implementation of procedures to monitor and prevent Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations) or other opportunistic waterborne pathogens, hand hygiene, placement of urinary dependent drainage bag, and the sanitary storage of respiratory equipment. This deficient practice placed the residents at risk for complications related to infectious diseases.

Inspectors wroteThe facility identified a census of 116 residents. The sample includes 24 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being and had the potential to affect all residents. Findings Included: - An inspection of the facility revealed a suggestion box, located inside a walkway area that required a door code to access. The facility inspection revealed the facility had no labeled grievance boxes in place. On 06/04/24 at 10:19 AM, the Resident Council (RC) members reported they were not aware of how to file a grievance, or if the facility provided a way to file an anonymous grievance. [...]

Inspectors wroteThe facility identified a census of 116 residents. The sample included 24 residents with two residents sampled for pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, due to pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure staff followed the intervention in place for pressure-reducing boots for Resident (R) 14 to prevent the possible development of a pressure ulcer. This deficient practice placed R14 at risk for complications associated with skin breakdown.

Inspectors wroteThe facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for falls. Based on observation, record review, and interviews, the facility failed to identify and implement appropriate, resident-centered interventions to prevent falls for cognitively impaired Resident (R) 96. This placed R96 at risk for additional falls and or injuries.

Inspectors wroteThe facility identified a census of 116 residents. The sample included 24 residents with three residents reviewed for bowel and bladder. Based on observations, record review, and interviews, the facility failed to provide the necessary care and services related to incontinence (lack of voluntary control over urination or defecation) care for Resident (R) 33, who had a history of urinary tract infections (UTI- infection of the urinary tract system) and failed to provide the necessary care and services related to indwelling catheters for R415. This deficient practice placed R33 and R415 at risk for UTIs and related complications.

Inspectors wroteThe facility identified a census of 116 residents. The sample included 24 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure the oxygen tubing was stored in a sanitary manner to decrease exposure and contamination for Resident (R)413. This deficient practice placed R413 at increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R) 60 had a documented risk assessment, a consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the R60 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails.

Inspectors wroteThe facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat a mental disorder characterized by gross impairment in reality testing) for Resident (R) 71 and R92, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). This placed these residents at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications.

Inspectors wroteThe facility identified a census of 116 residents. The sample included 24 residents with six residents sampled for hospice services. Based on observation, record review, and interview, the facility failed to ensure a consistent method of communication process, including how the communication would be documented between the facility and the hospice provider, to ensure the needs of the resident were addressed and met 24 hours per day for Resident (R) 5. This placed R5 at risk of decline and/or from maintaining the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThe facility identified a census of 116 residents. The sample included 24 residents with five residents reviewed for immunizations. Based on record review, and interviews, the facility failed to obtain consent or declinations for Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination or administration information for Residents (R) 53 and R71. This placed the residents at increased risk for complications related to pneumonia.

Inspectors wroteThe facility identified a census of 113 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent Resident (R) 1, who was cognitively impaired and at risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff), from exiting the facility without staff knowledge or supervision on 11/26/23 at 01:23 PM. R1 pushed on a door leading to the stairwell for 15 seconds and was able to open the door. The door alarm sounded but the roam alert system (system which alerts when a linked roam alert bracelet is near) did not alert even though R1 wore a roam alert bracelet. Staff reset the door alarm but did not check the stairwell. [...]

Inspectors wroteThe facility identified a census of 101 residents. The sample included 21 residents with 21 reviewed for reasonable accommodation of needs. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 6's call light remote was within reach while in her room. The facility additionally failed to ensure foot pedals were provided for Resident (R) 14's, R22's, and R19's wheelchairs to prevent their feet from dragging on the floor. This deficient practice placed R6 at risk unmet care needs and R14, R22, and R19 at risk for injuries. Findings Included: [...]

Inspectors wroteThe facility identified a census of 101 residents. The sample included 21 residents with four reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed follow up on identified changes in R61 bowel and bladder incontinence. This deficient practice placed the residents at risk for complications related to incontinence. Findings Included: - The Medical Diagnosis section within R61's Electronic Medical Records (EMR) included diagnoses dementia (progressive mental disorder characterized by failing memory, confusion), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), muscle weakness, history of falling, need for assistance with personal cares, chronic kidney disease, major depressive disorder (major mood disorder), and abnormal gait and mobility. [...]

Inspectors wroteThe facility identified a census of 101 residents. The sample included 21 residents with two reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to provide orders to administer supplemental oxygen to Resident (R)6. The facility additionally failed to store R5 and R6's supplemental oxygen equipment (masks and tubing) in a sanitary manner. This deficient practice placed R6 at risk for complications related to respiratory care and infections. Findings Included: [...]

Inspectors wroteThe facility identified a census of 101 residents. The sample included 21 residents. Five residents were sampled for medication review. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified that Resident (R) 14's anti-hypertensive (a medication used to treat elevated blood pressure) medication was given outside of physician ordered parameters. This deficient practice placed R14 at risk for unnecessary medication administration and adverse side effects.

Inspectors wroteThe facility identified a census of 101 residents. The sample included 21 residents. Five residents were sampled for medication review. Based on observation, record review and interview, the facility failed to ensure Resident (R)14's anti-hypertensive (a medication used to treat elevated blood pressure) medication was given within the physician ordered parameters. This deficient practice placed R14 at risk for unnecessary medication administration and adverse side effects.