Inspection Reports for
Lakeview Post Acute

The facility failed to ensure proper foot and wound care was performed for one resident, resulting in an infected great toe wound and failure to document a blister on the second toe in skin assessments. The wound was left uncovered until the wound management company assessed it, and treatment orders were delayed.

The facility failed to provide adequate hot water temperatures for bathing and personal care in multiple resident rooms and shower rooms, with temperatures consistently below the facility's policy and state regulations. Several residents reported dissatisfaction with the water temperature being too cold or taking too long to warm up.

The facility failed to provide a homelike environment by not maintaining appropriate hot water temperatures for bathing and personal care, affecting multiple residents. The plan of correction includes replacement of water heaters and valves, and implementation of ongoing water temperature monitoring.

The facility failed to ensure proper wound care and medication administration, including failure to apply leg wraps as ordered, failure to provide showers and incontinence care, failure to maintain wound vac supplies and follow wound care orders, inaccurate documentation of treatments, and inadequate pest control resulting in gnats in resident rooms. These deficiencies affected multiple residents and posed risks of harm.

The facility failed to meet professional standards in comprehensive care plans, activities of daily living care, wound care, resident records, and pest control. Deficiencies included failure to apply leg wraps as ordered, inadequate personal hygiene care, incomplete clinical documentation, and ineffective pest control measures.

The complaint investigation was substantiated with findings of drug diversion by LPN A on 11/12/24. The nurse was terminated and arrested. The police report identified felony stealing of controlled substances. Witnesses included LPN B and the former Administrator.

The facility failed to prevent the unauthorized removal of controlled medications for one resident, resulting in the termination of the responsible nurse and police involvement. Additionally, the facility failed to ensure working call lights in residents' bathrooms and bathing areas for four sampled residents.

The facility was found deficient in multiple areas including failure to ensure resident dignity, failure to notify responsible parties of significant changes or incidents, failure to report abuse allegations, inadequate wound care and treatment documentation, failure to prevent resident elopement, insufficient staffing levels and supervision, failure to provide appropriate training and competency for tracheostomy care and equipment use, medication administration errors, and malfunctioning call light systems.

The facility had multiple deficiencies including failure to ensure resident dignity, inadequate call light response, failure to notify responsible parties of significant incidents, incomplete care plans, medication administration errors, insufficient staffing, inadequate infection control practices, and failure to maintain safe bed rails and call light systems.

The investigation focused on Resident #12 who required tracheostomy care. The complaint was substantiated as the facility failed to provide adequate respiratory care and documentation.

The facility failed to obtain physician orders and complete tracheostomy care and suctioning as required for a resident needing such care. Documentation of treatments and orders for suctioning and tracheostomy care was incomplete or missing on multiple dates, leading to inadequate respiratory care.

The investigation was complaint-related, focusing on the failure to obtain and follow physician orders for tracheostomy care. The report indicates the deficiency was substantiated with findings of inadequate orders and documentation.

The facility failed to have physician orders and documentation for routine tracheostomy care, including suctioning and changing equipment, for Resident #12. Multiple instances showed lack of documentation and orders for tracheostomy care from April through July 2024, resulting in inadequate respiratory care and several emergency hospital transfers due to low oxygen saturation.

The facility failed to have a documented maintenance program for their piped-in medical gas system, which could affect occupants in multiple halls. The inspection revealed missing documentation of inspections, incomplete maintenance schedules, and issues with manifold alarm wiring and system components.

The facility was found deficient in multiple areas including failure to develop comprehensive, person-centered care plans, inadequate assistance with activities of daily living, incomplete wound and pressure ulcer treatments, failure to implement dietary recommendations for residents with severe weight loss, and failure to provide adaptive eating equipment as ordered. All deficiencies were cited with minimal harm or potential for actual harm.

The investigation was complaint-related, focusing on the failure to prevent falls for a resident who was identified as high risk and subsequently died after a fall and cardiac arrest.

The facility failed to develop a care plan with interventions to prevent falls for a resident identified as high risk. The resident fell from a wheelchair, suffered a seizure, went into cardiac arrest, and was pronounced dead at the hospital.

The facility failed to ensure residents consistently received scheduled showers due to inadequate staffing, failed to develop care plans addressing fall risks leading to a resident fall and death, failed to complete wound treatments as ordered especially on weekends, failed to implement dietary recommendations for residents with severe weight loss, failed to provide adaptive eating equipment as ordered, failed to maintain safe water temperatures for resident bathing, and failed to ensure nurses were trained and aware of ventilator alarms and backup equipment.

The complaint investigation was triggered by allegations that residents did not receive showers as scheduled, wound treatments were not properly managed, pressure ulcers were not prevented or treated appropriately, and a resident fell due to improper use of transfer lifts. The investigation confirmed these issues with multiple residents.

The facility failed to provide showers according to resident preferences and schedules, failed to ensure wound treatment orders were timely and accurately implemented, failed to prevent pressure ulcers and provide appropriate care, and failed to ensure safe resident transfers, resulting in falls. Deficiencies included missing shower documentation, incomplete wound treatment documentation, inconsistent use of heel protectors, and improper use of mechanical lifts.

The facility was found deficient in multiple areas including failure to notify responsible parties of resident condition changes, failure to timely report suspected abuse, failure to inform residents of bed hold policies, failure to administer prescribed wound care and antibiotics leading to resident harm and death, failure to complete wound assessments and treatments, failure to turn and reposition residents with pressure ulcers, and failure to follow physician orders for enteral feeding and document accurately.

The complaint investigation found that staff did not respond when Resident #4 cried out for help and the call light was not within the resident's reach. Staff were observed talking in the hallway instead of responding. Interviews with staff and the Director of Nursing confirmed expectations that call lights be accessible and staff respond promptly. The resident reported not knowing how to get help and mentioned facility rules about going back to bed.

The facility failed to ensure that a resident's call light was accessible and that staff responded promptly when the resident cried out for help. Observations and interviews confirmed that the call light was out of reach and staff did not respond timely, violating the resident's rights to self-determination and dignity.

The facility failed to promote and facilitate resident self-determination, as evidenced by a resident's call light being inaccessible and staff not responding to calls for help. The resident was found yelling for assistance with no staff response, and the call light was located on the floor out of reach.

The complaint investigation was triggered by reports that residents were not receiving showers as scheduled, wound care treatments were not timely or properly documented, pressure ulcer care was inadequate, and a resident eloped from the facility without staff knowledge or supervision.

The facility failed to ensure residents received showers according to their preferences and schedules, failed to timely and accurately update wound treatment orders and documentation, and failed to provide appropriate pressure ulcer care including consistent use of heel protectors. Additionally, the facility failed to provide adequate supervision for a resident who eloped from the facility.

The complaint involved allegations that CNA A was rude, forced a resident to transfer beyond their ability, removed the resident's wheelchair out of reach while on the commode, ripped the resident's briefs off without consent, and left the resident exposed and unattended on the toilet. The resident reported nightmares and fear of retaliation. The facility investigation was unable to substantiate willful abuse but found failures in care and reporting. CNA A was suspended.

The facility failed to ensure residents were treated with dignity and respect, as CNA A ignored the resident's request and left the resident exposed on the toilet. The facility also failed to substantiate allegations of willful abuse but acknowledged deficiencies in care and reporting. Additionally, the facility failed to provide appropriate pressure ulcer care and consistent skin assessments for two residents, resulting in untreated or inadequately treated pressure ulcers.

The complaint involved allegations that a Certified Nursing Assistant (CNA) was rude, failed to assist a resident properly, removed the resident's wheelchair, and left the resident exposed on the toilet. The facility investigated but was unable to substantiate willful abuse. The CNA was suspended. The resident reported nightmares and fear of retaliation. The family and Social Services Director were involved in follow-up.

The facility failed to ensure staff treated a resident with respect and dignity, resulting in the resident being exposed on the toilet and experiencing nightmares and fear of retaliation. Additionally, the facility failed to provide adequate care and treatment for pressure ulcers for two residents.

The facility failed to promptly resolve grievances and properly inform residents about grievance procedures. Medication administration was often delayed or undocumented, wound treatments were frequently not documented as completed, and food temperatures were not consistently taken or maintained at safe levels.

The facility failed to promptly resolve grievances, maintain grievance policies, and notify residents of grievance procedures. Employee background screening was incomplete. Medication administration errors and documentation deficiencies were noted. Insulin storage and labeling were improper. Food temperatures were not consistently monitored or maintained. Infection control practices were deficient, including catheter care. Code status documentation was inconsistent and incomplete for many residents.

The complaint investigation was substantiated as the facility failed to address grievances timely, maintain grievance records, and provide adequate care related to medication administration, wound care, and infection control. Multiple resident complaints were verified through interviews and record reviews.

The facility failed to make prompt efforts to resolve grievances, maintain grievance records, and identify a grievance official. Deficiencies were found in abuse/neglect policies, background checks, medication administration, wound care, infection control, food safety, and documentation of resident care. Several residents reported issues with medication timing, staff behavior, and care quality.

The complaint investigation was substantiated as the facility was found to have violated residents' rights to receive visitors at any time, with enforcement of visiting hours after 8:00 P.M. and denial of visitation leading to family complaints and police involvement.

The facility failed to protect residents' rights to receive visitors at their choosing, enforcing visiting hours that restricted access after 8:00 P.M. This resulted in family members being denied visitation and incidents involving police intervention.

The facility failed to ensure proper treatment and care for a resident's wound as ordered by the physician, including inadequate dressing changes and documentation. The nursing care per resident condition was also found deficient.

The facility failed to meet professional standards in administering medications, including administering medications without physician orders and using medications belonging to other residents. Interviews and record reviews confirmed these deficiencies.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness. However, the facility failed to designate one or more individuals with specialized training in infection prevention and control as required by regulation.

The facility was found deficient in multiple areas including failure to accommodate resident food preferences and adaptive equipment, improper management of resident trust accounts, failure to provide required Medicare notices, lack of timely transfer/discharge notices and bed hold policy notifications, failure to meet professional standards in medication administration and care, inadequate perineal and oral care, insufficient treatment of pain, wounds and eye irritation, unsafe resident transfers, improper storage of potentially hazardous items, improper use and monitoring of bed rails, food service safety violations, and lapses in infection control practices.

The facility was found deficient in multiple areas including fire alarm system access and maintenance, sprinkler system maintenance, portable fire extinguishers installation and maintenance, smoking regulation enforcement, smoke barrier door maintenance, oxygen storage, and gas equipment storage. The deficiencies had the potential to affect building occupants and residents.

The facility failed to provide adequate treatment and care for one resident with a non-pressure-related injury, including incomplete wound care documentation and improper wound treatment practices. The Director of Nursing confirmed that nurses were expected to follow physician orders and proper infection control procedures, which were not consistently met.

The facility failed to ensure staff properly locked the Hoyer lift during resident transfers, posing a risk of injury. Observations and interviews confirmed multiple instances where the lift was not secured as required.

The facility failed to thoroughly assess and notify physicians of changes in residents' conditions, resulting in delayed emergency response for a stroke. Additionally, the facility had significant medication errors, including a resident receiving 10 times the ordered dose of morphine, leading to hospitalization.

The facility failed to protect a resident from harm during transfer with a mechanical lift due to a defective sling strap, resulting in the resident falling and sustaining fractures. The investigation included interviews, record reviews, and assessment of equipment and policies.

The complaint investigation was substantiated with findings of deficient practices in resident rights, care, and facility policies. The facility was cited for multiple deficiencies related to the complaint allegations.

The facility was found deficient in multiple areas including failure to ensure residents' rights to timely assistance with eating and drinking, inadequate management of resident funds, failure to post survey results and complaint information, and lack of proper abuse and neglect policies and training. Numerous care plan and medication administration deficiencies were also identified.

The facility failed to maintain exit discharge surfaces, fire sprinkler system maintenance, portable fire extinguishers, smoking regulations, and combustible decorations in accordance with NFPA standards. These deficiencies affected all residents, staff, and occupants in the event of a fire.