Lakewood Villa

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#1 and #2) of eight residents reviewed for abuse out of eight sample residents were free from abuse. Specifically, the facility failed to ensure Resident #1 and Resident #2 were free from abuse by each other.

Inspectors wroteBased on record review and interviews, the facility failed to ensure four (#2, #3, #6 and #9) of nine residents reviewed for abuse out of 13 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #2 from physical abuse by Resident #3; -Protect Resident #6 and Resident #3 from physical abuse from each other; and, -Protect Resident #9 from physical abuse by Resident #3.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food items were stored, prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to have a system in place to monitor the internal water temperature and concentration (parts per million-ppm) of hypochlorite of the dish machine in the main kitchen to ensure tableware, drinkware and cookware were effectively sanitized.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff used the correct surface disinfectant products; -Ensure enhanced barrier precautions (EBP) were in place for a resident with a stage IV pressure injury prior to wound care; and, -Ensure washing machine temperatures were checked daily and lint traps were emptied timely.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that its medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 6.45%, which was two errors out of 31 opportunities for error.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one resident (#3) out of 29 sample residents. Specifically the facility failed to ensure insulin pens were primed prior to medication administration for Residents #3. Cross-reference F759 failure to ensure the medication error rate was less than five percent (%).

Inspectors wroteBased on interviews and record review, the facility failed to protect and keep residents safe from physical abuse for one (#37) of three residents reviewed for physical abuse out of 29 sample residents. Specifically, the facility failed to protect Resident #37 from physical abuse by a staff member.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure two (#1 and #2) out of five sample residents at risk for elopement, received adequate supervision and facility assistive devices to prevent elopement. Specifically, the facility failed to provide Resident #1 and Resident #2 the supervision necessary to prevent elopements. These facility failures created a situation with serious harm and a situation with the likelihood of serious harm to residents' health and safety if not immediately corrected. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to: -Take the appropriate measures to control a mice problem in the facility including failing to eliminate or minimize food sources; and, -Attempt to eliminate the mice from entering the facility through door gaps and holes.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents resided in a sanitary and comfortable environment for two of two units observed for cleanliness. Specifically the facility failed to: - Ensure resident rooms, dining rooms, hallways, kitchen floors and furniture were free from debris, food and mice droppings (cross reference F 925 pest control); -Ensure resident furniture and hand rails in common areas were in good repair; and, -Ensure the resident's courtyard was free of hundreds of cigarettes extinguished and disposed of on the ground.

Inspectors wroteIII. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included vascular dementia moderate with other behavioral disturbance, other lack of coordination, wandering in disease classified elsewhere, suicidal ideations and macular degeneration (deterioration of the eye). The 6/1/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of seven out of 15. He required limited assistance of one person for bed mobility, transfers and walking in his room. He required extensive assistance of one person for walking in the corridor, locomotion on and off the unit and dressing. He required extensive assistance of two people for eating. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for two (#25 and #27) of five residents out of 27 sample residents. Resident #25, who was known to be at risk for weight loss due to hemiplegia (paralysis of one side of the body), dementia and dysphagia (difficulty with swallowing), experienced a choking episode on 3/27/23. The facility downgraded the resident to a pureed diet (a diet of foods that do not need to be chewed) and the resident was evaluated by a speech therapist and placed on the speech therapy caseload due to swallowing difficulties for one month. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and one out of two nourishment rooms. Specifically, the facility failed to: -Ensure one unit nourishment room was clean and sanitary; -Ensure the kitchen ceiling was free from debris and dust; -Ensure appropriate hand washing occurred in the main kitchen; and, -Ensure dishes were dried appropriately.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for one of two medication carts and one of one medication storage rooms. Specifically the facility failed to: -Remove expired medications from medication carts and medication storage rooms to prevent the use of expired medications; -Date insulins, eye drops and inhalers when opened; and, -Ensure the medication storage refrigerator temperature was within acceptable parameters.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had a right to participate in the development and implementation of their person-centered plan of care for two (#9 and #23) of two out of 27 sample residents. Specifically, the facility failed to invite and conduct regular care conferences to review the resident's plan of care with Resident #9 and Resident #23.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to take steps to protect three (#27, #47 and #40) of seven residents reviewed for abuse out of 27 sample residents. Specifically, the facility failed to ensure: -Resident #47 was free from physical abuse from Resident #40; -Resident #40 was free from physical abuse from Resident #47; and, -Resident #27 was free from physical abuse from Resident #12.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible for one (#14) of five residents reviewed out of 27 sample residents. Specifically, the facility failed to: -Consistently track behaviors to justify the use of an antipsychotic medication for a resident with dementia for Resident #14; and, -Attempt an annual gradual dose reduction (GDR) of an antipsychotic medication for a resident with dementia, as is required unless it is clinically contraindicated, for Resident #14.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one (#12) of five residents reviewed out of 29 sample residents remained free from resident-to-resident altercations. The facility failed to implement person-centered interventions and evaluate the effectiveness of the interventions for Resident #12 to protect other residents involved in altercations, and provide person centered care to prevent persistent abuse by Resident #12. Based on the facility's failure to protect Resident #12 and the other residents involved with the altercations, the resident was involved in eight resident-to-resident altercations from 11/26/18 to 10/22/19 which contributed to the harm caused to Resident #31 and Resident #5 on two different occasions. Conversely, Resident #12 was harmed in an altercation with with Resident #1.

Inspectors wroteBased on record review and interview, the facility failed to ensure one (#12) of five residents reviewed for dementia care of 29 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. The facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #12 to prevent resident-to-resident altercations, provide an activity program that was personalized to avoid group activities since she desired low stimulation, and address repeated behavioral issues created an environment where abuse persisted. Based on the facility's failure to protect Resident #12 and the residents involved with the altercations, it caused harm to Resident #31 and Resident #5 on two different occasions. [...]

Inspectors wroteBased on observations and staff interview, the facility failed to provide adequate outside ventilation by means of windows or mechanical ventilation, or a combination of the two. Specifically, the facility failed to ensure resident bathroom exhaust fans were functioning properly to ensure good air circulation and minimize unpleasant odors.

Inspectors wroteBased on resident interview, record review and staff interviews, the facility failed to inform a resident, of the facility's bed hold policy, for one (#18) resident reviewed for hospitalization out of 29 sample residents. Specifically, the facility failed to ensure Resident #18 was informed, verbally and in writing, of the bed hold policy while on leave from the facility when he transferred to the hospital.