Lakeview Nursing Center

In the surveyor’s words

From the most serious findings on record at Lakeview Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF600Mar 31, 2023

  Based on record reviews, staff interviews, resident interviews, Resident Representative (RR) interview, job description reviews, and policy and procedure reviews, the facility failed to prevent neglect of a resident (Res) #1 from occurring by neglecting to document/record the treatment and services accessible to five (5) of five sampled residents reviewed for bowel functioning programs. Res. #1, #2, #3, #4 and #5. This failure had the potential to affect all residents in the facility. Resident #1 was admitted to the hospital with vomiting and stomach pain on [DATE] and later died from aspiration due to vomiting as a result of a bowel impaction on [DATE]. Resident #1 had no documented bowel movements (BM's) for 11 days prior to the hospital admission on [DATE]. […]

• Immediate jeopardy, widespreadF656Mar 31, 2023

  Based on interviews, record reviews and policy and procedure reviews the facility did develop and/or implement the bowel functioning Care Plans for five (5) of five (5) residents reviewed. Resident (Res) #1, Res #2, Res #3, Res #4, and Res #5 had no implemented bowel functioning programs maintained in the medical records. This failure had the potential to affect all residents in the facility. The facility's failure to implement the bowel functioning/constipation care plan for Res #1 and to render the care and services necessary to prevent constipation resulted in her admission to the hospital on [DATE] and her death on [DATE] from aspiration from vomiting due to small bowel obstruction. […]

• Immediate jeopardy, widespreadF684Mar 31, 2023

  Based on observations, record review, interviews, and policy and procedure reviews, the facility failed to implement the facility's protocol for monitoring bowel functioning for five (5) of five (5) residents reviewed, Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5, which resulted in Resident #1 becoming ill with vomiting and stomach pain and transferred to the hospital on [DATE]. On [DATE], Resident #1 died at the hospital as a result of a bowel impaction/obstruction. The facility's failure to render the care and services necessary to prevent constipation resulted in the death of Resident #1. […]

• Immediate jeopardy, widespreadF835Mar 31, 2023

  Based on record review, observations, job description reviews, interviews, and policy and procedure reviews, the facility administration failed to identify the staff's failure to monitor residents bowel movements and provide treatment and services to prevent avoidable changes in residents medical conditions as evidenced by the lack of documentation or the inaccurate documentation of five (5) of five (5) sampled residents bowel movement regimens. Resident (Res) #1, #2, #3, #4 and #5. This failure had the potential to affect all residents. The facility's failure to provide administrative oversight and supervision to prevent Res #1's constipation resulted in the ultimate death of Resident #1. […]

• Immediate jeopardy, widespreadF865Jan 23, 2021

  Based on staff interviews, record reviews, and facility policy review, the facility failed to provide documented evidence that it has, through its Quality Assurance and Performance Improvement (QAPI) Program, failed to call meetings to review and analyze data regarding the three (3) COVID-19 outbreaks within the facility in an effort to prevent the continued spread of COVID-19 prior to the State Agency (SA) entering the facility on 1/19/21, for a COVID-19 survey. This had the potential to affect 75 of 75 residents in the facility. The failure of the facility to utilize the QAPI program to determine the root cause of the COVID-19 outbreaks and identify deficient practices was likely to cause serious injury, harm, impairment, or death. […]