Lakewest Rehabilitation and Skilled Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 9 (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10) of 14 reviewed for Abuse. The facility failed to protect Residents #2, #3, #4, #5, #6, #7, #8, #9, #10 from physical and verbal abuse by another resident. An IJ was identified on 4-16-2026. The IJ template was provided to the facility on 4-16-2026 at 3:40 PM. While the IJ was removed on 4-17-2026, the facility remained out of compliance at a scope of pattern and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective measures. This failure placed residents at risk of subsequent abuse resulting in potential mental anguish, emotional distress, and physical harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 3 of 8 Residents (Residents #6, #7, #8 ) reviewed for abuse and neglect. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for four of six residents (Resident #1, #2, #3, and #5) reviewed for the resident rights. The facility failed to ensure the call light system in Resident #1, #2, #3, and #5's room was in a position that was accessible to the residents on 03/05/26. This failure could place residents at risk of being unable to obtain assistance when needed, and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 6 residents (Resident #4 ) reviewed for care plan. The facility failed to ensure Resident #4's care plan reflected a plan of care for the resident's use of a BiPAP device. This failure could place residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents (Resident #4) reviewed for respiratory care. The facility failed to ensure Resident #4's breathing treatment masks were properly stored in a bag when not in use on 03/05/26. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 5 residents of 25 residents (Resident #17, Resident #89, Resident #57, Resident# 66, Resident #63) reviewed for ADLs. The facility failed to ensure:1. Residents #17, #57, and #63's fingernails were trimmed.2. Residents #89 and #66's fingernails were cleaned and trimmedThese failures could place residents who were dependent on staff for ADL care at a loss of dignity and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for four of seven Residents (Resident #17, Resident #8, Resident #89, and Resident #3) reviewed for quality of care.1. The facility failed to implement interventions to prevent further decline of Resident #17's contracture to his left wrist.2. The facility failed to implement interventions to prevent further decline of Resident #8's contracture to his left hand.3. The facility failed to implement interventions to prevent further decline of Resident #89's contracture to his left hand, right hand and shoulder. 4. The facility failed to implement interventions to increase range of motion for Resident #3's upper and lower extremities. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 24 residents (Resident #98, Resident #68, Resident #12, and Resident #17) and 1 of 4 linen closets (Linen Closet for Hall 100) and the facility's only laundry room observed for infection control. 1. The facility failed to ensure CNA D and LVN E utilized Enhanced Barrier Precautions during incontinence care for Resident # 98 on 01/11/26. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 1 (Resident #65) of 7 residents reviewed for resident rights. The facility failed to ensure staff distributed unopened mail packages to Resident #65. This deficient practice could result in residents not receiving their mail in a timely manner and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two of 25 (Residents #17 and #89) reviewed for comprehensive care plans. 1. The facility failed to include, in the care plan for Resident #17, his left wrist contracture and interventions to prevent further decline.2. The facility failed include, in the care plan for Resident #89, his contracture to his left hand, right hand and shoulder and interventions to prevent further decline of Resident #89'sThese failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care and did not represent a person-centered coordination of care.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #39 and Resident #48) of 4 residents reviewed for wound treatment.1. The facility failed to provide care for Resident #39's wounds as identified on the resident's physician's orders on 1/9/2025.2. The facility failed to provide care for Resident #48's wound and obtain physician order for another wound that had reopened on 1/8/2025. These failures could place residents at risk for delayed wound healing or worsening of the exiting wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities for 1 (Resident #55) of 2 residents reviewed for prescription eyeglasses. The facility failed to follow up in a timely manner on prescription eyeglasses for Resident #55 after his eye exam was completed on 7/17/25. This deficient practice and failure could place residents at risk for worsening vision and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents (Resident #17 and Resident #98) reviewed for quality of care. 1. The facility failed to ensure CNA C provided appropriate perineal care for Resident #17 when she failed to clean the resident's penis downward and the pubic area on 01/12/26. 2. The facility failed to ensure CNA B provided appropriate catheter and perineal care for Resident #98, when she failed to separate the labia and wipe the catheter tubing from the insertion site downward while providing care on 01/12/26. These failures could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy for 1 (Resident #3) of 3 residents reviewed for therapy services. The facility failed to provide physical therapy for Resident #3 after her PT evaluation, recommending therapy, was completed on 8/15/25. This failure could place residents at risk for decline in range of motion, decreased mobility, development of contractures, and a decline in quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for one (Resident # 22) of one resident reviewed for PASRR services. The facility did not initiate the application process for the Durable Medical Equipment / Customized Wheelchair for Resident #22 within twenty days, per PASRR recommendations made during the PASRR Care plan meeting held on 05/08/2025. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Resident room [ROOM NUMBER]) of three resident rooms reviewed. The facility failed to ensure Resident #1 swallowed and consumed all of her pills and supplements prior to leaving Resident #1 alone in her room on 06/13/25 with the medications. During a medication pass, medications must be under the direct observation of the person administering the medications. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 (Resident #2) of 5 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from abuse on 05/14/25, when Resident #1 hit Resident #2 in the back of his head with his walking cane which caused 2 hematomas (localized collection of blood outside of blood vessels, often due to injury). An Immediate Jeopardy was identified on 06/10/2025. The IJ template was provided to the facility on [DATE] at 3:31 PM and signed by the ADM. While the IJ was removed on 06/11/2025, the facility remained out of compliance at a scope of isolated and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 (Resident #2) of 2 residents reviewed for resident rights. The facility failed to move Resident #2 to a temporary room on the nights of 5/12/2025 and 5/13/2025 when Resident #2 complained that the room was too hot. This failure could place residents at risk for living in an uncomfortable and unhomelike environment which could cause a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #24) of 5 residents reviewed for pharmacy services. The facility failed to correctly transcribe Resident #1's medication changes when he returned to the facility on [DATE] after hospitalization. The incorrectly transcribed medication was administered from 03/2025 to 05/13/25. These failures could place residents at risk for medication errors, ineffective relief from pain medication, and drug diversion of controlled substances.

Inspectors wroteBased on observation, record review and interview, the facility failed ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers from developing for 4 (Resident #2, Resident#3, Resident#4 and Resident#5) of 5 residents reviewed for pressure ulcers. The facility failed to ensure Resident#2's pressure relieving mattress functioned properly on 03/20/25. The facility failed to have pressure relieving mattress set to the correct weight settings for Resident #3's, Resident#4, and Resident#5 to prevent pressure ulcers or skin breakdown on 03/20/2025 and 03/21/25. These failures could affect residents at risk for pressure ulcers of developing new or worsening existing pressure ulcers.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of five residents reviewed f1or infection control. On 03/20/25 and 03/21/25 CMA E, CNA F and HK G failed to put on PPE before entering Resident#1 room. This failure could place residents at risk of cross contamination of infections from other residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 (Resident #1) of 1 resident reviewed for tracheostomy care. The facility failed to ensure Resident#1's oxygen concentrator was functioning properly on 03/20/25 and 03/21/25. This failure could place residents at risk of serious injury or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the facility's one of four halls (Hall 100) reviewed for pest control. The facility failed to keep an effective pest control program to ensure the residents' rooms of resident room [ROOM NUMBER] and 115 including bathrooms were free of roaches and water bugs. This failure could place residents at risk for reduced quality of life and poor sanitary environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed to protect Resident #1 from physical and verbal abuse by CMA C. On 09/18/24 at 7:30 PM, CMA C threw a pitcher of water at Resident #1 which caused him to get wet. CMA C also used profanity at Resident #1. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 09/18/24 at 7:30 PM and ended on 09/30/24. The facility had corrected the noncompliance before the Incident investigation began on 02/24/25. This failure could place residents at risk for serious injury or harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food items in walk-in refrigerator were sealed and produce did not show signs of expiration. 2. The facility failed to ensure food temperatures of hamburger patties, chicken nuggets, fries, ice cream and gelatin dessert were obtained prior to serving lunch on 11/06/24. 3. Dietary Aide N, LVN J and Dishwasher O wore effective hair restraints during lunch meal service on 11/06/24. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #69, Resident #86, Resident #47, and Resident #33) of 14 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #69 had his fingernails cleaned and trimmed. 2- Resident #86 had his fingernails cleaned and trimmed. 3- Resident #47 received shower on his scheduled day. 4- Resident #33 had his fingernails cleaned. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 3 medication carts (Nurses cart hall 300, Med Aide cart hall 300/400, and Nurses cart hall 400) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure: 1- LVN D, responsible for Nurses Cart Hall 300, removed medications in unsecure blister packs from the Nurses Cart. 2- MA E, responsible for Med Aide Cart Hall 300/400, removed medications in unsecure blister packs from the Med Aide Cart. 3- LVN F, responsible for Nurses Cart Hall 400, removed medications in unsecure blister packs from the Nurses Cart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 residents (Resident #3 and Resident#83) of 4 residents observed for infection control. The facility failed to ensure: 1- CNA A performed hand hygiene between change of gloves during incontinent care for Resident #3. 2- LVN C and CNA B donned the appropriate PPE during wound care for Resident #83 who was on enhanced barriers precautions. These failures could place residents at risk for infection and cross contamination of pathogens and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for 1 (Resident #40) of 8 residents reviewed for quality of care. The facility failed to ensure Resident #40 received foot care and treatment for her dry, flaky skin on her feet. These failures placed all residents at risk for not receiving foot care which is consistent with professional standards of practice.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration for one (Resident #5) of six residents reviewed for quality of care. The facility failed to ensure Resident #5 was provided adequate hydration on 11/05/24. This failure could place residents at risk of dehydration and decline in nutritional status.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food that was at an appetizing temperature and palatable for one (11/06/24) of one meal reviewed for food palatability and temperature. The facility failed to serve hamburger at an appetizing temperature and vegetables at a palatable texture during the lunch meal on 11/06/24. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a Resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 2 (Resident #1) reviewed for respiratory care The facility failed to ensure Resident #1 Oxygen humidity bottle and nasal cannula were labeled or dated. These failures could place the resident at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, establish policies and procedures to investigate any such allegations for two (Residents #1 and #2) of eleven residents reviewed for abuse. 1. The facility failed to implement and follow their abuse, neglect, and exploitation policy to ensure Resident #1 was safe from abuse when CNA A reported that Resident #3 was observed touching Resident #1's shoulder area of her body on 08/22/2024. 2. The facility failed to implement and follow their abuse, neglect, and exploitation policy to ensure Resident #2 was safe from abuse when CNA B reported that Resident #4 was observed using his cane to hit Resident #2 over the head on 08/19/24 or 08/20/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for two (Residents #1 and #2) of eleven residents reviewed for abuse. 1. The facility failed to investigate the alleged or suspected abuse of Resident #1 to ensure all resident's safety, when CNA A reported that Resident #3 was observed touching Resident #1's shoulder area of her body. 2. The facility failed to investigate the alleged or suspected abuse of Resident #2 to ensure all resident's safety, when CNA B reported that Resident #4 was observed using his cane to hit Resident #2 over the head. These failures could place all residents at risk for abuse and psychosocial harm.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records that were complete and/or accurate for three (Residents #1, #2, #4) of seven residents reviewed for clinical records. 1. Resident #1's Foley catheter (a medical device that helps drain urine from the bladder) volume was not recorded per physician's orders on 10/13/23 and 10/14/23. 2. Resident #1's wound care to her stage four pressure wound to her coccyx (a small triangular bone at the base of the spinal column) was not documented as being completed per physician's orders on 10/06/23 and 10/09/23. 3. Resident #2's treatment administration record reflected he was not administered insulin per physician's orders on 10/02/23, 10/03/23 and 10/09/23. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (Resident #2 and Resident #4) of seven residents reviewed for care plans. 1. The facility failed to ensure Resident #2's comprehensive care plan addressed his newly acquired infection of sepsis and pneumonia, his use of antibiotics, and related interventions. 2. The facility failed to ensure Resident #4's comprehensive care plan addressed her wound care on her amputated toe, her blood infection and use of antibiotic via a PICC line. The failures could place residents at risk of receiving inadequate interventions not individualized to their health care needs.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary that included but is not limited to, (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for two (Residents #3 and #5) of two residents reviewed for discharge planning. 1. The facility failed to complete a discharge summary for Resident #3 when he had a planned discharge home. 2. The facility failed to complete a discharge summary, discharge plan of care and a reconciliation of medications for Resident #5 when he had a planned discharge home. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for residents, staff, and the public for four (Halls 100, 200, 300, and 400) of four hallways reviewed for housekeeping services. The facility failed to ensure the floors in resident rooms on Halls 100, 200, 300, 400 and the dining hall, were maintained in a clean and sanitary manner. This failure could place residents at risk for diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure all irregularities identified by the Pharmacist Consultant were reported to the attending physician and acted upon to minimize or prevent adverse consequences to the extent possible for 1 (Resident #55) of 24 resident reviewed for drug regimen reviews. The facility failed to have in writing the Pharmacist Consultant's recommendation for a gradual dose reduction for Resident #55's antianxiety medication, in return there was no documentation in the pharmacy review book that the medical director agreed or disagreed. These failures could place residents who require monthly drug regimen reviews and placed them at risk of receiving unnecessary medications and adverse drug consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and assure only authorized personnel to have access to the keys for 1 (Resident #42) of 7 residents reviewed for pharmacy services, in that: 1. The facility failed to ensure Resident #42 eye drops were stored in a secured place. 2. The facility failed to ensure the Nurse Medication Cart for Hall 300/400 was locked when unattended. This failure could place residents at risk of not receiving the therapy needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 (Resident #26, Resident #65, Resident #31, and Resident #25) of 7 residents reviewed for infection control during medication administration. 1. MA D failed to disinfect the blood pressure cuff in between blood pressure checks for Resident #26, Resident #65, and Resident #31. 2. The facility failed to ensure that its infection control policy was followed in Resident #25's room. These failures could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 32 residents (Resident #96) reviewed for dignity. CNA A failed to use privacy curtain or close the door when providing incontinent care for Resident #96. This deficient practice could place residents at risk for psychosocial harm due to a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, disposition, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #27) of 7 residents and one cart for hall 300 reviewed for pharmacy services. 1. MA D did not check Resident #27's blood pressure or pulse rate before administering Lisinopril 10mgs 1 tablet (blood pressure medication), as ordered by Resident #27's physician. 2. The facility failed to dispose of one expired bottle of docusate 100mgs tablets from hall 300 cart. This failure could place residents who take blood pressure medications at risk for hypotension (low blood pressure) and resident on hall 300 at risk of receiving expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items were properly labeled, dated, and thawed in accordance with professional standards. These failures could place residents, who receive food from the kitchen, at risk for food contamination and food-borne illness.