5 Reports
Inspection Report — Apr 22, 2025
Complaint Investigation CMS
Date: Apr 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident 1 eloped from the facility, triggering a WanderGuard alert and resulting in injury.
Complaint Details
The investigation was triggered by a complaint related to Resident 1 eloping from the facility on 04/13/25. The complaint was substantiated as the facility failed to provide adequate supervision and timely search response, placing Resident 1 in immediate jeopardy.
Findings
The facility failed to provide adequate supervision to prevent an elopement of a cognitively impaired resident and did not conduct a thorough search immediately after the alert. Resident 1 was found injured outside the facility and required hospital evaluation and treatment.
Deficiencies (1)
F0689: The facility failed to ensure staff provided adequate supervision to prevent an elopement for Resident 1 and failed to conduct a thorough search in response to a WanderGuard alert, resulting in Resident 1 exiting the building and sustaining injuries.
Report Facts
Fall risk score: 17
Elopement risk score: 10
Time staff responded to alarm: 36
Time until Resident 1 was found: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse E | Administrative Nurse | Reported the elopement incident and notified administrative staff |
| Administrative Staff A | Administrative Staff | Reviewed door codes and cameras post-incident and provided statements on expected staff actions |
| Administrative Nurse D | Administrative Nurse | Received call about fall and elopement, obtained witness statements, and provided expectations for staff response |
| CNA M | Certified Nurse Aide | Responded to door alarm and participated in search for Resident 1 |
| CNA N | Certified Nurse Aide | Assisted CNA M during response to door alarm |
| Licensed Nurse G | Licensed Nurse | Described staff procedures for responding to WanderGuard alarms |
Inspection Report — Jun 5, 2024
Routine CMS
Date: Jun 5, 2024
Visit Reason
Routine inspection of Lakeview Village nursing home to assess compliance with regulatory standards across multiple areas including resident rights, pressure ulcer care, fall prevention, catheter care, respiratory care, use of bed rails, psychotropic medication use, food safety, hospice services, infection control, and immunizations.
Findings
The facility had multiple deficiencies including failure to implement an anonymous grievance system, inadequate pressure ulcer prevention, insufficient fall prevention interventions, improper catheter and incontinence care, unsanitary storage of oxygen equipment, lack of documented risk assessment and consent for bed rails, inappropriate use of psychotropic medications without documented rationale, improper food storage practices, inadequate hospice communication and care planning, lapses in infection control practices, and failure to obtain pneumococcal vaccination consents or declinations.
Deficiencies (11)
F 0585: The facility failed to implement a system to allow residents and their representatives to file grievances anonymously, placing residents at risk for decreased psychosocial well-being.
F 0686: The facility failed to ensure staff followed pressure ulcer prevention interventions for Resident 14, placing the resident at risk for skin breakdown complications.
F 0689: The facility failed to identify and implement appropriate, resident-centered fall prevention interventions for cognitively impaired Resident 96, placing the resident at risk for additional falls or injuries.
F 0690: The facility failed to provide appropriate catheter and incontinence care for Residents 33 and 415, including lapses in hand hygiene and peri-care, placing residents at risk for urinary tract infections and complications.
F 0695: The facility failed to ensure oxygen tubing was stored in a sanitary manner for Resident 413, increasing risk for respiratory infection and complications.
F 0700: The facility failed to ensure Resident 60 had a documented risk assessment, consent, and advisement of risks and benefits for use of bed rails, placing the resident at risk for uninformed decisions and impaired safety.
F 0758: The facility failed to provide physician-documented rationale including unsuccessful nonpharmacological interventions and risk versus benefits for continued antipsychotic use for Residents 71 and 96, placing them at risk for unnecessary psychotropic medication and related complications.
F 0812: The facility failed to ensure proper food storage and handling practices, including unlabeled, undated, uncovered food items and improperly stored dishes, placing residents at risk for foodborne illnesses.
F 0849: The facility failed to ensure consistent communication and documentation between the facility and hospice provider for Resident 5, placing the resident at risk for delayed services affecting well-being.
F 0880: The facility failed to ensure proper infection control practices including hand hygiene, placement of catheter bags, storage of respiratory equipment, and monitoring for Legionella, placing residents at risk for infectious disease complications.
F 0883: The facility failed to obtain consent or declination documentation for pneumococcal vaccination for Residents 53 and 71, placing them at increased risk for pneumococcal disease complications.
Report Facts
Sample size: 24
Residents reviewed for pressure ulcers: 2
Residents reviewed for falls: 5
Residents reviewed for bowel and bladder care: 3
Residents reviewed for hospice services: 6
Residents reviewed for immunizations: 5
Inspection Report — Dec 19, 2023
Complaint Investigation CMS
Date: Dec 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a cognitively impaired resident (R1) who eloped from the facility without staff knowledge or supervision on 11/26/2023.
Complaint Details
The investigation was triggered by a complaint regarding resident R1 eloping on 11/26/2023. The complaint was substantiated with findings that the roam alert system failed and staff did not respond properly to door alarms, resulting in immediate jeopardy to resident health and safety.
Findings
The facility failed to provide adequate supervision and appropriate response to door alarms to prevent the elopement of R1, who exited the building via a stairwell door. The roam alert system failed to activate properly, and staff did not respond adequately to the door alarm, placing the resident in immediate jeopardy.
Deficiencies (1)
F 0689: The facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping through a stairwell door when the roam alert system did not activate and staff did not respond appropriately to the door alarm.
Report Facts
Elopement risk score: 6
Temperature: 32.2
Duration of elopement: 6
Door push duration: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Witnessed door alarm, reset alarm, and received a final written warning for responding to door alarms |
| Dietary BB | Intercepted resident R1 after elopement and escorted him back to long term care | |
| Administrative Staff A | Investigated the elopement incident and provided statements about alarm system failure and staff expectations | |
| Administrative Nurse D | Notified about the incident and described staff expectations for responding to door alarms | |
| Licensed Nurse G | Provided observations about resident R1's behavior on the day of elopement |
Inspection Report — Jan 12, 2023
Routine CMS
Date: Jan 12, 2023
Visit Reason
Routine inspection of Lakeview Village nursing home to assess compliance with regulatory standards including resident care, medication administration, respiratory care, and accommodation of resident needs.
Findings
The facility failed to ensure foot pedals were provided on wheelchairs to prevent residents' feet from dragging, failed to keep call lights within reach for a resident, failed to follow up on changes in bowel and bladder incontinence, improperly stored respiratory equipment, failed to provide supplemental oxygen orders and proper equipment storage, and failed to ensure medication administration within physician ordered parameters.
Deficiencies (7)
The facility failed to ensure foot pedals were provided for residents R14, R19, and R22's wheelchairs to prevent their feet from dragging on the floor, placing them at risk for injury.
The facility failed to ensure Resident R6's call light remote was within reach while in her room, placing her at risk for falls and unmet care needs.
The facility failed to follow up on identified changes in Resident R61's bowel and bladder incontinence, placing residents at risk for complications related to incontinence.
The facility failed to ensure Resident R5's CPAP mask was properly stored when not in use, placing her at risk for respiratory complications and infection.
The facility failed to provide orders to administer supplemental oxygen to Resident R6 and failed to store her oxygen equipment in a sanitary manner, placing her at risk for respiratory complications and infections.
The facility failed to ensure the Consultant Pharmacist identified and reported when Resident R14's anti-hypertensive medications were administered outside of physician ordered parameters, placing her at risk for unnecessary medication administration and adverse side effects.
The facility failed to ensure staff administered Resident R14's anti-hypertensive medications within physician ordered parameters, placing her at risk for unnecessary medication administration and adverse side effects.
Report Facts
Residents reviewed: 21
Residents reviewed for bowel and bladder management: 4
Residents reviewed for respiratory care: 2
Residents sampled for medication review: 5
Medication administration opportunities outside parameters: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Provided statements regarding wheelchair foot pedals, call light use, CPAP mask storage, oxygen tubing maintenance, and medication administration flags. |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding wheelchair foot pedals, call light placement, CPAP mask and oxygen equipment storage, and medication administration review process. |
| Certified Medication Aide R | Certified Medication Aide | Provided statements regarding wheelchair foot pedals and CPAP mask storage. |
| Certified Medication Aide G | Certified Medication Aide | Provided statements regarding call light use and bowel/bladder incontinence. |
Inspection Report — Jul 12, 2021
CMS
Date: Jul 12, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Lakeview Village, a nursing home facility, related to a regulatory survey completed on July 12, 2021.
Findings
No health deficiencies were found during the survey.
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