Lakeridge Villa Health Care Center

In the surveyor’s words

From the most serious findings on record at Lakeridge Villa Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF740Sep 20, 2021

  Based on medical record review, interviews with facility staff, hospital record review, observations, and facility policy review, the facility failed to provide adequate behavioral health services for one Resident (#3) with a known history of [CONDITION(S)] and suicide attempts. This resulted in Immediate Jeopardy when Resident #3 cut himself on three separate dates (05/18/21, 07/19/21, and 09/01/21) in an attempt to commit suicide. This affected one Resident (#3) out of three residents (#3, #10, and #11) identified by the facility with a history of [CONDITION(S)]/attempts. […]

• Immediate jeopardy, isolatedF604Mar 3, 2021

  Based on medical record review, observations, staff interviews, review of witness statements, review of the facility restraint use policy, and review of facility abuse policies, the facility failed to ensure residents were free from any physical restraint imposed for staff convenience, to restrict movement, and not required to treat the resident's medical symptoms. This resulted in Immediate Jeopardy and the potential for physical harm, psychosocial harm, and mental anguish for one resident (#37) who, as any reasonable person would be, was dehumanized by being tied to the bed like an inanimate object with the use of bed sheets and was not being treated in a dignified manner in full recognition of their individuality. […]

• Actual harm, isolatedF760Nov 24, 2021

  Based on medical record review, review of hospital records, staff interview, review of facility policy and review of medication information from Medscape, the facility failed to administer medications as ordered by the physician resulting in a significant medication error. This resulted in Actual Harm for Resident #56 who missed nine doses of her anti-[CONDITION(S)] medication ([MEDICATION(S)]) and was subsequently transferred to the hospital where the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected one (#56) of three residents reviewed for medication administration. Facility census was 90. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF803May 7, 2024

  Based on review of the menu, review of the substitution log, observation, staff interview, and policy review, the facility failed to ensure the menu was followed. This affected all 90 residents who received meals from the kitchen. Resident #13 received no food by mouth. The facility census was 91. Findings include: Review of the breakfast menu, dated 05/06/24, revealed residents on a regular diet were to be served six ounces of hot or cold cereal, a number sixteen scoop or two ounces of cheesy scrambled eggs, and one slice of toast. Residents on a mechanical diet were to be served six ounces of hot or cold cereal, a number sixteen scoop or two ounces of cheesy scrambled eggs, and one slice of toast. […]

• No harm, potential for more than minimal, widespreadF812May 7, 2024

  Based on observation, staff interview and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner and the dishwasher had the appropriate level of chemicals in order to prevent foodborne illness. This had the potential to affect all 90 residents who received meals from the kitchen. Resident #13 received no food by mouth. The facility census was 91. Findings include: 1. Observation of the kitchen on 05/06/24 at 8:15 A.M. revealed there were food debris built up in the oil and on the edges of the fryer. There was also food debris on the fryer basket and a brown splatter on the side of the fryer. There was brown water on the floor of the kitchen on the opposite side of the steam table where food was served during tray line. […]