Lakewood Nrsg & Rehab Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a resident's change in condition with subsequent Physician notification, resulting in a delay of care and hospitalization. This applies to 1 resident (R69) reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with LVADs (Left Ventricular Assist Devices) received care and services to ensure their LVADs were functioning. This failure resulted in an Immediate Jeopardy (IJ). The Immediate Jeopardy began on [DATE] when R1 experienced a change in condition and staff did not know to assess the function of his LVAD. R1 experienced cardiac arrest, was emergently transferred to the hospital, and later expired. This applies to 1 resident (R1) reviewed for LVADs and has the potential to affect 1 other resident (R4) in the facility that uses an LVAD. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the IJ on [DATE] at 10:36 AM and the IJ template was provided. The facility presented an Immediacy Removal Plan on [DATE] at 2:16 PM, which was returned for revision at 3:22 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a training plan was in place to educate licensed staff (including agency staff) on specialty care needs. This has the potential to affect all 113 residents in the facility. Based on interview and record review, the facility failed to ensure a training plan was in place to educate licensed staff (including agency staff) on specialty care needs. This has the potential to affect all 113 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to assess the urinary status of a resident with an indwelling urinary catheter. This failure resulted in the resident experiencing urinary retention and being hospitalized with a diagnosis of UTI (Urinary Tract Infection). This applies to 1 of 3 residents (R1) reviewed for catheters in a sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure residents felt safe voicing grievances without fear of retaliation. This applies to 10 of 10 residents (R31, R36, R45, R48, R49, R50, R63, R79, R82, R167) reviewed for grievances in the sample 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents, who were identified as needing assistance, with hygiene and grooming. This applies to 5 of 5 residents (R54, R81, R86, R366, R368) reviewed for ADL (activities of daily living) in the sample of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate and timely accounting of controlled medications, and failed to ensure that narcotic medication is stored in a sealed packaging. This applies to 4 of 5 residents (R5, R32, R91, R315) reviewed for controlled medications in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label medication for the date it was opened to determine expiration date. The facility also failed to remove medication upon its used by date. This applies to 4 of 6 residents (R4, R32, R33, R315) reviewed for labeling and storage of medication in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu extension sheet to provide portions as shown for mechanical soft and pureed consistency diets. This applies to 6 of 6 residents (R2, R14, R17, R19, R33, and R34) reviewed for dining.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices during provisions of ADL (Activities of Daily Living) care, medication pass, or while providing therapy services. This applies to 6 of 6 residents (R15, R86, R111, R265, R365, R366) reviewed for infection control in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the electronic monitoring alarm control panel was functioning. This applies to 4 of 4 resident (R48, R58, R70, R95) reviewed for use of electronic monitoring devise in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to do a smoking assessment and revise the plan of care when a resident resumed smoking. This applies to 1 of 1 residents (R71) reviewed for smoking in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that foot care is provided for a resident who needs total assistance for personal care. This applies to 1 of 1 resident (R56) reviewed for foot care in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's order for oxygen administration. The facility also failed to change the oxygen tubing and maintain water level in humidifier bottle per facility's policy and procedure. This applies to 1 of 1 resident (R81) reviewed for oxygen therapy in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's order during medication administration. There were 26 medication opportunities with 2 errors resulting to 7.69% medication error rate. This applies to 1 of 4 residents (R15) reviewed for medication administration in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide lunch meal options of similar nutritive value to the main entree. This applies to 2 of 2 residents (R32, R266) reviewed for dining in the sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and provide appropriate adaptive eating equipment to maintain ability to eat independently for a resident identified with limited range of motion on the upper extremities. This applies to 1 of 1 resident (R51) reviewed for adaptive eating equipment in the sample of 23.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide timely tracheotomy (trach) care to a resident with a tracheotomy that required suctioning as needed to maintain the airway and Oxygen levels. This failure has caused severe respiratory distress, oxygen desecration, and the need for hospitalization. This applies to 1 of 3 residents (R1) reviewed for respiratory care and treatment in a sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident who was having a decline in health condition. This applies to 1 of 3 residents (R1) reviewed for change in health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal hygiene for 6 residents (R25, R97, R73, R3, R37 & R64), who are dependent on ADL care (Activities of daily living) in a sample of 27.

Inspectors wroteBased on observation interview and record review the facility failed to update physician orders to reflect residents' resuscitation choice of DNR (Do Not Resuscitate) This applies to 1 of 2 residents (R56) reviewed for code status in a sample of 27 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to verify G tube (gastric tube) placement for 1 resident (R71) in a sample of 27.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to provide oxygen therapy to resident dependent on continuous oxygen and contain reusable nebulizer treatment masks, and BIPAP masks (two levels of air pressure machine). This applies to 4 of 4 residents (R5, R97, R165 and R167 ) reviewed for respiratory care in a sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to provide thickened drinks as ordered by the physician for a resident with swallowing difficulties. This applies to one resident R56 reviewed for diet in a sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during provisions of personal care and medical treatments to residents. This applied to 4 of the 27 residents (R40, R72, R307, R309) observed for privacy during care and treatment in the sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to assist residents identified as needing assistance with oral care, bathing/shower and personal hygiene. This applies to 10 of 11 residents (R10, R30, R41, R57, R67, R72, R82, R89, R306, R307) reviewed for ADL (activities of daily living) in the sample of 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow recipe for pureed breaded fish and cheese sandwich and failed to use scoop sizes as shown on menu spread for pureed and mechanical soft diets. This applies to 9 of 9 residents (R16, R24, R36, R40, R57, R72, R96, R256, R308) observed for dining in the sample of 27. 1. On 04/10/23 at 11:55 AM, V14 (Dietary Manager) was at the steam table during lunch meal service in the facility kitchen platting foods for the pureed diets. V14 used a #8 scoop to serve pureed Beef Stroganoff to R57, R72, R96, R256). R57 was served pureed diet in bowls and ate in dining room. R256, R96, and R72 received room trays. Facility Menu Daily Spreadsheet for week 1, Monday showed to use #6 scoop of pureed Beef Stroganoff for pureed diets. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to serve mechanical soft consistency fruit for the lunch meal. This applies to 5 of 5 residents (R14, R25, R39, R41, R81) observed for dining in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control process related to hand hygiene and gloving during provisions of care. This applies to 5 of the 7 residents (R51, R72, R96, R307, R308) observed for infection control during provisions of care in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to offer residents the influenza and pneumococcal vaccine. This applies to 5 of 5 residents (R10, R5, R17, R45, and R78) reviewed for immunizations in the sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and provide adaptive equipment and services to residents, to prevent further reduction in mobility and ROM (range of motion). This applies to 2 of 3 residents (R36 and R82) reviewed for mobility and range of motion in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on using a gait belt when transferring a resident. This applies to 1 of 2 residents (F306) reviewed for transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent urinary tract infection. In addition, the facility failed to ensure that an indwelling urinary catheter is secured or anchored to the resident to prevent from potential pulling. This applies to 3 of 7 residents (R72, R96, R307) observed for incontinence and catheter care in the sample of 27.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident receives the intravenous medication as ordered by the physician. This applies to 1 of 1 resident (R156) reviewed for intravenous medication in the sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the plan of care for behavior monitoring for a resident receiving psychotropic medication. This applies to 1 of 5 residents (R61) reviewed for psychotropic's in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve milk prior to the expiration date and ensure that the milk provided was not spoiled. This applies to 2 of 2 residents (R30, R51) observed during dining experience in the sample of 27.