Lakeland Village Nursing Facility

In the surveyor’s words

From the most serious findings on record at Lakeland Village Nursing Facility, in the surveyor’s own words.

• Immediate jeopardy, patternF812Sep 27, 2024

  Based on observation, interview, and record review the facility failed to test modified fluid consistencies after preparation and before serving to vulnerableresidents at risk for aspiration (inhalation of food, liquid, or other material into the airway or lungs) in accordance with professional standards of practice and resident needs for 3 of 9 sampled residents (Residents 8, 30 and 43), reviewed for food and nutrition services. In addition, the facility failed to ensure that foods were stored and prepared in a safe manner, and dishwasher temperatures met the required standard which placed residents at risk for food borne illness and diminished quality of life for all 75 residents. […]

• Actual harm, isolatedF689Jun 18, 2021

  Based on observation, interview, and record review, the facility failed to ensure nursing staff used safe lifting techniques while transferring residents for one of three sample residents (1), reviewed for accidents. Failure to transfer Resident 1 as per the care plan resulted in actual harm, when the resident sustained bruising and swelling to the leg and perineal area, which required two emergency room (ER) visits for evaluation. Findings included Per the 03/17/2021 quarterly assessment, Resident 1 had diagnoses which included profound intellectual disability, was non-verbal, and communicated needs and pain through facial expressions, reaching out, and making noises. […]

• No harm, potential for more than minimal, widespreadF880Sep 27, 2024

  Based on observation, interview, and record review the facility failed to review policies yearly as required, perform hand hygiene and/or glove changes when indicated, handle, store, and transport laundry in a manner to prevent the spread of infection. In addition, the facility failed to place signage in a conspicuous location outside the residents' room to clearly identify transmission based precautions implemented and appropriate personal protective equipment (PPE) to be used, and implement enhanced barrier precautions to prevent the spread of multidrug-resistant organisms (MDROs) for 1 of 3 sampled residents (Resident 14), reviewed for infection control. […]

• No harm, potential for more than minimal, patternF802Sep 27, 2024

  Based on observation, interviews and record review, the facility failed to ensure all staff had food handler's cards (a certification that showed staff had completed training on food safety) to prepare food for facility residents. Specifically, in 6 of 7 cottages, the staff were occasionally preparing and cooking some foods, without food handler's cards. In addition, 1 of 24 dietary staff (C) had an expired food handler's card. This failed practice had the potential risk for unsafe food handling practices and placed all residents at risk for developing foodborne illness. […]

• No harm, potential for more than minimal, patternF812Mar 16, 2023

  Based on observation, interview, and record review, the facility failed to ensure cleaning supplies were used per manufacturer recommendations in the 3-compartment sink in the main kitchen and on the main kitchen food preparation surfaces, and in 5 of 7 (Harvest, [NAME], Ponderosa, Tamarack and Shamrock) resident cottage kitchen areas inspected. This failure placed residents at risk for food-borne illnesses and potential contamination of food items. Findings included . 3-Compartment Sink Sanitizer The undated 3 Compartment Sink facility policy showed that a sink with at least three compartments must be provided for manually washing, rinsing, and sanitizing equipment and utensils. […]