The Lakeland Center

Inspectors wroteThis citation relates to Intake 3047919. Based on observation, interview, and record review, the facility failed to protect the residents' rights to be right to be free from physical abuse for three Residents (R902, R903, R904) of four residents reviewed for abuse, which resulted in injuries for R902, R903, and R904.

Inspectors wroteThis citation pertains to intake #'s 2998574, 2991736 and 3001096. Based on observation, interview and record review, the facility failed to ensure sufficient staffing to meet resident needs for three residents (R801, R804 and R805) of four residents reviewed for staffing.

Inspectors wroteThis citation pertains to intakes 2615522, 2645363, and 2671721. Based on interview and record review, the facility failed to ensure that nursing staff received the required skills/competencies/performance evaluations for five of five Certified Nursing Assistants (CNA Y, Z, AA, BB, and CC) reviewed for education/training.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective Quality Assurance and Process Improvement (QAPI) Program that identified multiple systemic issues that needed improvement and correction. This had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the required committee members attended the Quality Assessment and Assurance (QAA) meetings at least quarterly. This had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain and implement an effective and operational compliance and ethics program for three (R6, R88, and R3) of three residents reviewed for binding arbitration, resulting in staff signing resident's names on legally bindings documents without their consent. This could potentially affect all residents who resided in the facility.

Inspectors wroteThis citation pertains to intakes 2603176, 2610188 and 2671721. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, safe, and homelike environment, affecting all residents that reside on the second floor, including R20, R23, R24, R39, R51, R72, R96, and R103 and residents that utilize the shower rooms on all units.

Inspectors wroteThis citation pertains to intake # 2610188. Based on observation, interview, and record review, the facility failed to ensure activity of daily living care (personal hygiene, bathing, nail care) for four residents, (R's 72, 6, 20, and 51) of six residents reviewed for activities of daily living, resulting in poor hygiene, body odor, complaints of not receiving care, and the potential for embarrassment from poor hygiene.

Inspectors wroteThis citation pertains to intakes 2615522, 2645363, and 2671721. Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff to meet the needs of the residents, resulting in delayed and/or lack of activities of daily living (ADL) care including incontinence care, dressing and showers/baths for residents that reside on the second floor, including R17, 27, 51, 54, 72, 96 and nine residents who wished to remain anonymous that attended the resident council interview.

Inspectors wroteThis citation pertains to Intake #'s 2615522 and 2610188. Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than five percent when five errors were made from 25 opportunities for two residents (R#'s 57 and 92) of three residents reviewed during the medication administration task, resulting in a medication error rate of 19%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure decision making was exercised by residents' court-appointed representatives for three (R3, R6, and R88) of three residents reviewed for arbitration.

Inspectors wroteThis citation pertains to intake #2615522. Based on observation, interview, and record review, the facility failed to promote resident self-determination through support of resident choice for two residents (R72 and R96) of two residents reviewed for self-determination and resident choice resulting in frustration, verbalized complaints, and the withholding of occupational therapy rehab services.

Inspectors wroteThis citation pertains to intake #2671721. Based on observation, interview and record review, the facility failed to ensure freedom from neglect for one resident (R96), of four residents reviewed for neglect resulting in R96's frustration and complaints that staff do not tend to their needs/requests when they activate their call light.

Inspectors wroteThis citation pertains to Intake Numbers: 2671563, 2671721. Based on observation, interview and record review, the facility failed to report an injury of unknown origin and an allegation of neglect to the Abuse Coordinator and State Agency, and failed to report resident to resident physical abuse to the State Agency without misleading information that minimized the seriousness of the incident for three (R22, R76, and R96) of five residents reviewed for abuse and neglect.

Inspectors wroteBased on observation, interview and record review the facility failed to thoroughly investigate an allegation of mistreatment for one (R28) of five residents reviewed for abuse/neglect.

Inspectors wroteThis citation pertains to intakes 2603176 and 2610478. Based on observation, interview and record review, the facility failed to implement interventions per plan of care following a resident to resident incident (between R51 and R16) for one (R51) of six residents reviewed for accidents.

Inspectors wroteThis citation pertains to intakes 2615522, 2645363, and 2671721. Based on interview and record review, the facility failed to ensure that one of five Certified Nursing Assistants (CNA 'AA') whose in-service training files were reviewed, had the required 12 hours of in-service training within the required time period.

Inspectors wroteBased on interview, and record review, the facility failed to adequately assess one (R22) of one resident reviewed for social services to ensure they received appropriate medically related social services.

Inspectors wroteBased on interview and record reviews the facility failed to ensure documentation of the resident/resident representative to have been offered the Influenza vaccine annually (R72) and ensure documentation of education to have been provided to the resident and/or resident representative for the Influenza immunization for two (R's 72 & 23 ) of five residents reviewed for Immunizations.

Inspectors wroteThis citation pertains to intakes 2615522, 2645363, and 2671721. Based on interview and record review, the facility failed to ensure that two of five Certified Nursing Assistants (CNAs 'AA' and 'CC') reviewed for required annual in-service education, had the required 12 hours of in-service training within the required time period which included abuse prevention and dementia care.

Inspectors wroteThis citation pertains to complaint: 2570541. Based on observations, interviews and record reviews the facility failed to ensure the resident call light system was fully operable and functioning for two of three residents observed. This deficient practice had the ability to affect multiple residents residing in the facility.

Inspectors wroteThis citation relates to Intake 1302878. Based on observation, interview, and record review, the facility failed to ensure proper positioning to prevent an avoidable fall with injury for one Resident (R703) of one resident reviewed for falls, which resulted in actual harm, with increased pain, emergent care, hospitalization, and fearfulness.

Inspectors wroteThis citation relates to Intake MI00153706. Based on interview and record review, the facility failed to follow a physician order to ensure proper catheter care per standards of practice for one Resident (R702) of one resident reviewed for catheter care.

Inspectors wroteThis citation relates to Intake #MI00151265. Based on observation, interview, and record review, the facility failed to provide adequate staffing to adequately meet the care needs of three Residents (R101, R102, and R105) of five residents reviewed for staffing, with the potential to affect all facility residents.

Inspectors wroteThis citation pertains to intake #MI00147045. Based on observation, interviews, and record review, the facility failed to consistently ensure sufficient nursing staff was provided for residents who resided in the facility, resulting in verbalized complaints of delayed care and services and the likelihood for further delayed care and unmet care needs. This deficient practice had the ability to affect all 66 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner and potentially hazardous food items were properly labeled and stored. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate infection control practices related to transmission based precautions (TBP) for five residents (R#'s 39, 48, 2, 51, and 66 ) of five residents reviewed for transmission based precautions, resulting in the potential for the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was revised to reflect non-pharmacological interventions for one resident (R42) of one resident reviewed for psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services met professional standards for two residents (R#'s 13 and 45) of four residents reviewed for professional standards during medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently follow physician's orders for notification of abnormal blood glucose levels and obtain additional orders for treatment for one resident, (R46) of one resident reviewed for insulin medication, resulting in the potential for adverse outcomes related to elevated blood glucose levels.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's notes were entered into the record at each visit and accurately addressed the resident's total program of care for one resident (R69), of one resident reviewed for physician visits.

Inspectors wroteBased on interview and record review, the facility failed to ensure individualized/person centered non-pharmacological interventions were in place for the use of psychotropic medications for one resident (R42) of five residents reviewed for unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than five percent when two medication errors of 26 opportunities for error were observed for two residents (R#'s 13 and 2) of four residents reviewed during the medication administration observation, resulting in a 7.69% medication error rate.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were not stored at the bedside for R67, expired medications were disposed, and insulin pens were properly dated of in one of three medication carts reviewed.

Inspectors wroteThis citation pertains to intake #MI00145151 Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was immediately reported to the abuse coordinator and reported to the State Agency for three residents, (R901, R902 and R903) of four residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteThis citation has two Deficient Practice Statements (DPS). DPS #1 This citation pertains to intakes MI00144702, MI00144797, and MI00144715. Based on observation, interview and record review, the facility failed to provide adequate supervision and implement elopement policies for one (R500) of four residents reviewed for elopement, resulting in a severely cognitively impaired resident being let out of a secured door to the patio by an unknown staff member, unsupervised and was found approximately 36 hours later, about five miles away from the facility. This deficient practice resulted in the likelihood for serious harm, injury, impairment, or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs that could cause negative outcomes, affecting all residents who resided in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to effectively maintain the physical plant for two residents (R15 and R24) and ensure a safe/homelike environment (rooms 201, 238 and 276), potentially effecting all residents who use the handrails for locomotion assistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (R8) of one reviewed for medication, was assessed for the safe self-administration of medication and to have medication kept at bedside.

Inspectors wroteThis citation pertains to intake #s MI00138743 and MI00139119. Based on interview and record review the facility failed to ensure an environment free from physical abuse for one resident (R18) of six residents reviewed for abuse/neglect/mistreatment, when R42 was physically aggressive with R18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document as needed (PRN) doses of medication for one resident (R1), of one resident reviewed for PRN medication administration, resulting in feelings of frustration.

Inspectors wroteDeficient Practice Statement (DPS) #1 Based on observation, interview, and record review the facility failed to appropriately position a resident (R32) in a specialized wheelchair, of one resident reviewed for positioning, resulting in the potential for aspiration of gastric (stomach) contents, increased intra-cranial (head) pressure/pain, decreased output from the heart, and decreased blood pressure.