Inspection Reports for
Lakeview Health Care &Amp; Rehabilitation Center

Complaint #1734617 involved allegations of physical abuse that were not reported timely and medication transcription errors. The investigation concluded the abuse allegation did not meet reporting requirements, but transcription errors posed a risk.

The facility failed to report an allegation of physical abuse within the required two-hour timeframe and failed to accurately transcribe a medication order for one resident, resulting in a risk of medication error. Both deficiencies were determined to cause minimal harm or potential for actual harm affecting a few residents.

The facility failed to review and revise the comprehensive care plans for two residents who sustained falls, despite policies requiring updates after each fall. Interviews with the MDS Coordinator and Director of Nursing revealed oversight in verifying that new interventions were added to care plans after falls.

The facility failed to follow infection control practices and implement outbreak testing when two residents became symptomatic for COVID-19. Staff did not test symptomatic residents promptly, and asymptomatic residents were not tested as per policy. Multiple residents showed symptoms but were not tested due to corporate office directives.

The complaint investigation found that symptomatic residents were not tested for COVID-19 as required, with corporate office advising against testing despite physician orders and resident symptoms.

The facility staff failed to conduct timely COVID-19 testing for symptomatic residents despite policy directives and physician orders. Multiple residents showed symptoms consistent with COVID-19, but testing was delayed or not performed due to corporate office advisement.

The facility failed to maintain a written emergency preparedness communication plan and failed to maintain two 2-hour fire barriers and three of four smoke barrier walls to ensure smoke tightness. Multiple breaches and unsealed holes were observed in fire barrier walls, posing risk to containment of smoke and fire.

The facility was found deficient in multiple areas including comprehensive care plans, activity programs, accident hazard prevention, nursing staffing, medication error rates, infection control, and employee screening. The facility failed to meet several regulatory requirements as evidenced by observations, interviews, and record reviews.

The facility failed to maintain an emergency preparedness communication plan and did not meet multiple life safety code requirements, including fire resistance ratings, sprinkler system maintenance, hazardous area door safety, and fire drill documentation. Several deficiencies were noted with potential to affect all facility occupants.

The facility was found deficient in multiple areas including failure to develop and update comprehensive person-centered care plans for residents, lack of weekend activities, unsafe storage of smoking materials for residents on oxygen, insufficient RN coverage on multiple days, incomplete daily nurse staffing postings, high medication error rate (50%), failure to prime insulin pens properly, lack of qualified dietary manager, and incomplete two-step TB testing for several employees. Deficiencies were generally cited at minimal or potential for minimal harm levels.

The facility failed to provide necessary treatment and services to prevent pressure injuries and promote healing for one resident, including incomplete weekly wound assessments and failure to notify the physician of wound deterioration. The facility's wound care protocols and documentation were found deficient.

The facility failed to provide appropriate pressure ulcer care by not completing weekly wound assessments and failing to notify the physician when a resident's pressure injury worsened. Documentation was incomplete, and treatment orders were not consistently followed or updated, resulting in actual harm to a few residents.

The facility was found noncompliant with multiple regulatory requirements including failure to post required hotline information, lack of accessible survey results, unsafe and unclean environment conditions, incomplete care plans, medication administration errors, inadequate infection control, and improper storage and labeling of drugs and food safety violations. The facility census was 42 during the inspection.

The facility was found deficient in multiple areas of the Life Safety Code including egress door locking arrangements, emergency lighting testing, hazardous area door maintenance, cooking facility range hood maintenance, fire alarm system testing, sprinkler system maintenance, electrical system safety, fire drills, and door inspections. The facility census was 42 with a capacity of 60.

The facility was found deficient in multiple areas including fire hazard due to missing drip pan in kitchen range hood, incomplete monthly resident summaries, unclean kitchen floors and walls, improper food storage and labeling, and freezer temperature maintenance issues. These deficiencies had the potential to affect all facility residents.

The facility was found deficient in multiple areas including failure to post required hotline information, maintain a clean and homelike environment, complete and update care plans, follow medication administration policies, ensure safe wheelchair propulsion, provide dialysis care documentation, complete bed rail assessments and consents, ensure nurse aide training compliance, maintain medication storage safety, keep kitchen and food storage sanitary, explain arbitration agreements properly, implement infection control procedures, and document influenza and pneumococcal vaccinations.

The facility had multiple deficiencies related to fire safety, including failure to request annual fire consultation, lack of posted evacuation diagrams, incomplete fire alarm testing records, improper storage of combustible materials, and failure to maintain emergency lighting and flame-resistant curtains. Some deficiencies were corrected by the re-inspection on September 13, 2023, but others remained partially addressed.

The facility failed to maintain proper emergency preparedness policies and procedures, maintain safe evacuation routes, and comply with fire safety codes including exit discharge pathways, sprinkler system maintenance, smoke barrier doors, smoking regulations, and electrical system safety. Several deficiencies were identified that could affect all facility occupants.

The facility failed to develop adequate emergency transportation policies, maintain sprinkler systems free of obstructions and corrosion, properly dispose of cigarette waste in designated smoking areas, and maintain a sufficient surety bond for resident funds. These deficiencies have the potential to affect all facility occupants.

The facility was found deficient in multiple areas including insufficient surety bond coverage for resident funds, failure to notify physician of resident's refusal of BiPAP use, inadequate assistance with activities of daily living for several residents, inadequate fall prevention measures, failure to provide catheter care to prevent infections, improper behavioral health care including inappropriate use of antipsychotic medication without documented non-pharmacological interventions, incomplete water management program to prevent Legionella growth, and failure to properly assess, test, and isolate residents for COVID-19.

The facility was found deficient in multiple areas including financial security assurance, notification of changes, assistance with activities of daily living, accident hazard supervision, bowel/bladder incontinence care, behavioral health services, infection control, and COVID-19 testing protocols. Several residents were identified as not receiving adequate care or supervision in these areas.

The facility failed to follow infection control measures, specifically proper hand hygiene during care for two residents, leading to a deficiency in the infection prevention and control program.

The facility failed to report a change in condition for one resident to the resident's physician when the resident was bleeding from his/her genital area. Staff interviews revealed inconsistent reporting and documentation of the bleeding incident.

The facility failed to follow acceptable infection control practices for COVID-19, including inadequate separation of COVID-19 positive and negative residents, improper use and disposal of PPE, failure to conduct proper screenings, and lack of signage and supplies for isolation rooms. The facility census was 54 at the time of the survey.

The facility was found noncompliant with multiple requirements including resident self-determination, surety bond for personal funds, safe environment, admission policy, activities program, psychotropic drug use, food safety, and infection control. Deficiencies were cited across these areas with plans of correction submitted.

The facility failed to inspect, test, and maintain fire doors located in the means of egress as required by NFPA 101. Records did not show documentation of an annual inspection of fire doors for the 12-month period, posing potential risk to all occupants.

The facility failed to maintain a sufficient surety bond for resident funds and did not maintain dishware sanitization at required chemical concentrations. Additionally, dishware was improperly stored wet, and sanitizing logs were not properly documented.

The complaint investigation was substantiated with findings of multiple deficiencies related to resident dignity, privacy, abuse, care planning, medication management, and infection control.

The facility was found to have multiple deficiencies including failure to respect resident dignity and self-determination, inadequate privacy protections, verbal abuse by staff, failure to develop and implement comprehensive care plans, improper medication storage and administration, and lapses in infection control and food safety practices. Several residents were observed in hospital gowns without personal belongings and restricted in an observation room.

The facility failed to meet several Life Safety Code requirements including incomplete emergency preparedness policies, failure to maintain fire egress doors, inadequate emergency lighting testing, incomplete fire alarm system documentation, and failure to conduct required fire drills. These deficiencies have the potential to delay evacuation and affect all facility occupants.

The facility failed to implement a safe and effective medication administration system, failed to wash hands properly to prevent cross contamination, and failed to ensure proper cleaning and sanitizing of food contact surfaces and kitchenware. Multiple deficiencies were observed related to documentation, hand hygiene, and food safety practices.