Inspection Reports for
Lakewood Senior Living

19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: Based on interview and record review, the facility failed to complete Individual Service Plans for five residents upon admission to the facility; review of residents' records and staff interviews showed ISPs were not documented.

19 CSR 30-88.010(29) Dignity/Privacy: Based on record review and interview, the facility failed to ensure all residents were treated with consideration, respect and full recognition of their dignity and individuality when a Certified Medication Aide became involved in a verbal altercation with a resident who declined to take medication.

19 CSR 30-88.010(22) Free From Abuse: Based on interview and record review, the facility failed to protect all residents from abuse when one staff member (Level One Medication Aide (LIMA) A) physically removed one resident and restrained the resident's hands against his/her will; staff failed to report allegations of abuse to management in a timely manner; LIMA A continued to work independently with residents after the allegations were overheard; and the facility failed to report the abuse to the State Agency in a timely manner.

19 CSR 30-86.047(56)(E)(1 - 2) Medications-Return to RX / Destroy, Records: Based on interview and record review, facility staff failed to maintain an accurate record of destroyed narcotic medications when significant doses were discovered missing and one narcotic did not match the count sheet for four residents. Narcotics were found in the DON's office and were not counted while there.

19 CSR 30-86.022(7)(E) Locked Exit Doors: Based on observation and interview on April 11, 2022, the facility failed to ensure delayed egress locks and required signage were installed/posted in accordance with applicable standards; multiple exit doors in the memory care unit lacked required delayed egress signage and required door code information, affecting residents.

19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds Protection from Hazards.: Based on observation and interview on April 11, 2022, the facility failed to ensure doors in a smoke partition were self-closing; a smoke door in the memory care unit did not close and latch when released from its electromagnetic hold-open device on multiple attempts, affecting residents.

19 CSR 30-86.047(19) TB Screen Residents & Staff: Based on interview and record review, the facility failed to ensure the required two-step tuberculosis screening tests were completed for three of six new staff members.

19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Based on record review and interview during the fire safety inspection process on March 27, 2019, the facility failed to maintain their sprinkler system. Annual inspection documentation showed dry pendant heads over ten years old and missing documentation of the ten-year dry head inspection.

19 CSR 30-86.022(10)(A) Hazardous Area Requirements: Surveyor observed that self-closing devices on doors leading to hazardous areas were not maintained or operational; the A hall mechanical room door self-closing device was broken and doors were being wedged or blocked open in the resident laundry and kitchen.

19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs: The facility failed to test and maintain emergency lighting; multiple emergency light fixtures failed to activate during testing in the television room, D hall and near the resident kitchen.

19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant: The facility did not show documentation that curtains and drapes were certified or treated as flame-resistant and numerous curtains throughout the facility had no documentation of fire-resistance.

19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility failed to use only metal or UL/FM fire-resistant rated wastebaskets; observations found multiple non-fire-resistant plastic, wire mesh and rubber wastebaskets in various areas.

19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to maintain the electrical system in good repair and lacked up-to-date inspection documentation; several GFCI duplex outlets did not function properly and the last documented electrical inspection was dated March 21, 2016.