Inspection Reports for
Lakewood Villa

The complaint investigation was substantiated with findings that Resident #1 and Resident #2 physically abused each other on 5/12/2025. The facility's investigation and interviews confirmed the incident and identified gaps in care planning and communication.

The facility failed to ensure that Resident #1 and Resident #2 were free from abuse by each other. The investigation found that Resident #2 kicked and hit Resident #1, who then hit Resident #2 in self-defense. The facility's care plans and interventions for Resident #2 were not fully implemented or documented, particularly regarding assistance to prevent collisions in the dining room.

The complaint investigation substantiated incidents of physical abuse by Resident #3 towards Residents #2, #6, and #9. The facility conducted investigations, updated care plans, and implemented interventions. Resident #3 had cognitive impairments and behavioral issues related to dementia. Staff interviews and documentation supported the findings.

The facility substantiated multiple incidents of physical abuse involving Resident #3 as both assailant and victim in altercations with Residents #2, #6, and #9. The facility had policies and procedures in place for abuse prevention and investigation, but failed to fully protect residents from abuse. Interventions and care plans were updated following incidents, and staff education and monitoring were ongoing.

The facility failed to maintain medication error rates below 5%, with a medication error rate of 6.45% due to improper insulin pen priming and incomplete medication orders. The kitchen dishwashing machine lacked proper monitoring of sanitizer concentration and temperature. Housekeeping staff did not follow proper cleaning and disinfecting protocols, including failure to disinfect high-touch surfaces and improper use of cleaning chemicals. Enhanced barrier precautions were not implemented for a resident with a stage IV pressure injury. Laundry washing machine temperatures were not monitored as required.

The complaint investigation was triggered by an agency CNA's report of poor treatment of residents. The investigation substantiated physical abuse of Resident #37 by an agency RN, confirmed by video surveillance. The agency RN was terminated and reported to the state board of nursing. The facility notified the resident's physician, representative, and local police.

The facility failed to protect Resident #37 from physical abuse by an agency RN, which was substantiated by video evidence. Additionally, the facility failed to maintain an effective infection prevention and control program, including improper cleaning techniques by housekeeping staff, failure to implement enhanced barrier precautions for a resident with a stage IV pressure injury, and inadequate laundry temperature monitoring.

The complaint investigation confirmed two residents (#1 and #2) eloped from the facility through an alarmed dining room door and unlocked outside gate. Resident #1 eloped on 12/24/23, was found stuck in a construction fence with frostbite, and did not return to the facility. Resident #2 eloped on 2/2/24, was found by police at a busy intersection, and returned to the facility with no injuries. The facility's alarm system was ineffective and staff failed to respond timely to alarms. Corrective actions were implemented and monitored.

The facility failed to provide adequate supervision and effective alarm system interventions to prevent resident elopements, resulting in one resident sustaining frostbite and another being found by police at a busy intersection. The facility implemented corrective actions including staff education, new alarm systems, gate improvements, and ongoing monitoring through QAPI meetings.

The facility was found to have multiple deficiencies including unsanitary conditions with debris, food, and mice droppings in resident rooms, dining rooms, hallways, and kitchen areas. Furniture and handrails were in disrepair, and the courtyard was littered with hundreds of cigarette butts. The pest control program was ineffective, with ongoing mice infestations and failure to address entry points such as door gaps and damaged door sweeps.

The investigation was complaint-driven, focusing on falls and accident prevention. The facility was found to have multiple failures related to supervision, assessment, neurological checks, and fall intervention implementation for residents with repeated falls.

The facility failed to ensure adequate supervision and effective fall prevention interventions for multiple residents at high risk of falls, including Resident #18 and Resident #25. The facility also failed to complete and document required registered nurse assessments and neurological checks following falls, and post-fall documentation was not completed timely. The Director of Nursing acknowledged these deficiencies and initiated a performance improvement plan.

The facility was found deficient in multiple areas including failure to ensure residents' participation in care planning, failure to protect residents from abuse, inadequate supervision to prevent accidents, failure to maintain residents' nutritional status, failure to implement gradual dose reductions of psychotropic medications, and failure to properly store and handle medications and food in accordance with professional standards.

The complaint investigation involved two incidents of resident-to-resident physical abuse. The facility did not substantiate the allegations due to residents' dementia and inability to recall the events, despite eyewitness staff accounts. The facility lacked documentation of staff education or interventions following the incidents.

The facility failed to ensure residents were free from resident-to-resident physical abuse. Two separate incidents were documented where Resident #2 pushed Resident #1 and Resident #4 slapped Resident #3. Both incidents involved residents with dementia and were witnessed by staff, but the facility did not substantiate the abuse due to residents' cognitive impairments and lack of recall. The facility also failed to provide evidence of staff education following the incidents.

The complaint investigation focused on resident-to-resident altercations involving Resident #12, failure to notify Resident #18 of bed hold policy during hospitalization, and inadequate ventilation in resident bathrooms.

The facility failed to protect Resident #12 and other residents from repeated resident-to-resident altercations resulting in actual harm. The facility also failed to inform Resident #18 of the bed hold policy during hospitalization and failed to maintain functional bathroom exhaust fans in multiple resident rooms.