Lakewood Manor

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to keep the kitchen's ice machine, electric mixer, manual can opener, food preparation pans, and a kitchen drawer which housed food preparation equipment clean; failed to cover and date stored foods; and keep the second-floor service kitchen's ice machine clean. This failure had the potential to affect all 84 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, clinical record review and facility documentation the facility staff failed to provide services as outlined in the comprehensive care plan that meet professional standards of quality for 1 Resident (#50) in a survey sample of 33 Residents.

Inspectors wroteBased on observation, and interview, the facility failed to make the results of their most recent survey conducted by Federal or State surveyors accessible for residents, family members, and legal representatives of residents to review. This failure had the potential to affect all 84 residents who resided in the facility.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to address unplanned significant weight loss; and ensured a comprehensive nutritional assessment was completed upon admission to maintain acceptable parameters of nutritional status for two of seven residents reviewed for nutrition (Resident (R) 83 and R13). This failure had the potential to affect other residents to not receive timely nutritional interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were stored and served under safe and sanitary conditions. Observations on 03/29/21 of the 200-floor kitchen revealed unlabeled and undated foods in the refrigerator. Additionally, observations during the 200-floor meal service on 03/29/21, revealed drinking glasses and dining plates were not handled in a sanitary manor. This deficient practice had the potential to affect 45 of 45 residents who were served meals from the 200-floor kitchen.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure the Resident Representative (RR) for one of three residents reviewed (Resident (R)81) was provided the Notice of Medicare Non-Coverage (NOMNC) at least 48-hours prior to the cessation of services. R81 was notified on 03/24/21 that their skilled services would end on 03/25/21. This failure had the potential for residents and/or their representatives not being informed of potential available services and fees for those services, or the advisement of the ability to appeal the Resident's discharge from Medicare Part A benefits.

Inspectors wroteBased on interviews and record reviews, the facility failed ensure the facility's abuse policy was followed for one of 22 sampled residents (Resident (R) 21). This includes completing a thorough investigation and reporting an injury of unknown origin. This deficient practice had the potential to affect all residents of the facility.

Inspectors wroteBased on interviews, policy review, and record reviews the facility failed to report an injury of unknown origin to the State Agency for one of six sampled residents reviewed for accidents (Resident (R) 21). On 08/04/20, R21 sustained a fracture to her left wrist and the injury was determined to be an injury of unknown origin; however, this was never reported to the State Agency.

Inspectors wroteBased on record review, facility policy review and staff interview, the facility failed to ensure a thorough investigation was completed for an injury of unknow origin for one of six residents reviewed for accidents (Resident (R) 21). On 08/04/20, R21 received a fracture to her left wrist; however, the cause of the fracture was not known.

Inspectors wroteBased on observation, record review, staff interview, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, the facility failed to ensure that the assessment accurately reflect the resident's status for two of 22 residents (Resident (R) 81 & R78). Review of the residents' comprehensive assessments revealed the residents were not accurately assessed for existing problems. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on observations, interviews, record reviews, and review of the facility's policy, the facility failed to provide activities of daily living (ADL) care for two of five residents reviewed for ADL, (Resident (R) 70 and R189). Observations revealed both residents had long white hairs on their chins, upper lips, and/or side of their face. This failure has the potential of affecting all dependent residents to not receive assistance with ADLs.

Inspectors wroteBased on observation, record review, staff and resident interview, and review of the facility's policy, the facility failed to ensure that residents received treatment and care in accordance with the comprehensive person-centered care plan and the residents' choices for one of 22 sampled residents (Resident (R) 81). R81 had a surgical wound on his scalp; however, the facility failed to complete weekly wound assessments. This deficient practice had the potential to place the resident at risk for complications related to wound healing.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure that one (Resident (R) 81) of four residents reviewed for pressure ulcers, received the physician ordered treatment, received complete incontinent care, qualified staff cleansed the wound, and was provided treatment in a correct manner.

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of two residents reviewed for urinary catheters (Resident (R) 81). On 03/30/21 during incontinence care, R81's urinary catheter bag was not placed below the resident's bladder for proper urinary drainage. This deficient practice had the potential to affect all residents who had a urinary catheter.

Inspectors wroteBased on observation, record review, staff interview, and facility policy review, the facility failed to ensure the intravenous (IV) dressings were changed as ordered by the physician and failed to ensure the resident's Peripherally Inserted Central Catheter (PICC) was flushed for one of one resident reviewed for parenteral fluids (Resident (R) 66). This deficient practice had the potential to cause infection at the IV insertion site.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to clean and air-dry nebulizer equipment between uses for one of 22 sampled residents (Resident (R) 81). This failure had the potential to cause pulmonary infections for the 14 residents in the facility that receive nebulizer treatments.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that one of five sampled residents reviewed for unnecessary medications were free from unnecessary medications (Resident (R) 67). R67 was ordered an antipsychotic medication; however, the facility failed to monitor for side effects of the medication; and failed to monitor for specific behaviors related to the indication of use for the medication. This failure had the potential to affect any resident who received an antipsychotic medication.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one newly admitted resident (Resident (R)189) out of eight newly admitted residents reviewed for isolation was placed in isolation with Transmission Based Precautions (TBP) for 14 days per the facility's policy. This failure had the potential to spread possible infections to other residents and staff of the facility.

Inspectors wroteBased on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed, for 1 resident of 29 residents (Resident #66) to document the administration of medication. For Resident #66, the facility staff failed to document the administration of medications for Depression, and Bowel Management. The Findings Included: Resident #66 was a [AGE] year old, admitted to the facility on [DATE]. Resident #66's diagnoses included constipation, depression, and age-related physical debility. The Minimal Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 7/12/18 coded her as having a Brief Interview of Mental Status Score of 6, indicating severe cognitive impairment. On 8/15/18 at 9:00 A.M. an observation was conducted of Resident #66 who was asleep in her room. [...]

Inspectors wroteBased on observation, resident and staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility staff failed for one Resident (Resident #18) in a survey sample of 29 residents, to ensure physician ordered pressure relieving boots were in place. The findings Included: Resident #18 was admitted to the facility on [DATE]. Diagnoses included: Congestive heart failure, urinary obstruction and chronic obstructive pulmonary disease (COPD). Resident #18's most recent MDS (minimum data set) with an ARD (assessment reference date) of 5-17-18 was coded as a quarterly assessment. Resident #18 was coded as having a BIMS (brief interview of mental status) of 15 out of a possible 15, or no cognitive impairment. [...]

Inspectors wroteBased on observation, staff interview and clinical record review the facility staff failed to ensure 2 residents (Resident #81, 68) of 29 residents in the survey sample were free from unnecessary psychotropic medications. 1. For Resident #81, a stop date was not indicated on the PRN (as needed) Lorazepam. 2. For Resident #68, a stop date was not indicated on the PRN (as needed) Lorazepam.

Inspectors wroteBased on observation, staff interview, and facility documentation review the facility staff failed to perform hand hygiene between two residents during medication administration. LPN (licensed practical nurse) A did not perform hand hygiene between Resident #80 and Resident #39 and Resident #45.