Lakewood Manor

In the surveyor’s words

From the most serious findings on record at Lakewood Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF888Aug 30, 2022

  Based on observation, staff interviews, facility documentation review, and clinical record review, the facility staff failed to implement their infection control policy and procedures with regards to COVID-19, including maintaining an accurate record of staff's COVID-19 vaccination status, conducting COVID-19 testing, wearing proper PPE (personal protective equipment). In addition, the facility had a COVID-19 outbreak, which resulted in 14 Residents testing positive for COVID-19 and one Resident (Resident #3) being hospitalized , which is harm. This noncompliance affected Residents on all 5 halls/units within the facility. Specifically, the facility staff failed to implement their infection control policies and procedures with regards to COVID-19, as evidenced by: 1. […]

• Actual harm, isolatedF692Apr 1, 2021

  Based on record review, interviews, and review of facility policy, the facility failed to address unplanned significant weight loss; and ensured a comprehensive nutritional assessment was completed upon admission to maintain acceptable parameters of nutritional status for two of seven residents reviewed for nutrition (Resident (R) 83 and R13). This failure had the potential to affect other residents to not receive timely nutritional interventions. Findings include: 1. Review of R83's undated Face Sheet, located in the resident's Electronic Medical Record (EMR), indicated R83 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Jun 23, 2023

  Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's ice machine, electric mixer, manual can opener, food preparation pans, and a kitchen drawer which housed food preparation equipment clean; failed to cover and date stored foods; and keep the second-floor service kitchen's ice machine clean. This failure had the potential to affect all 84 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Sanitation, dated 01/01/23, revealed, Policy: The food service area shall be maintained in a clean and sanitary manner. 2. All utensils, counters, shelves, and equipment shall be kept clean and maintained in good repair .12. […]

• No harm, potential for more than minimal, widespreadF880Aug 30, 2022

  Based on observation, staff interviews, facility documentation review, and clinical record review, the facility staff failed to implement infection control practices and failed to utilize proper PPE (personal protective equipment) as per the CDC (Centers for Disease Control and Prevention) and CMS (Centers for Medicare & Medicaid Services) guidance to prevent the spread of COVID-19 within the facility, on all 5 of the 5 Resident care halls and affecting 11 Residents (Resident #1, 5, 6, 7, 9, 10, 12, 13, 14, 16 and 20), in a survey sample of 20 Residents. The findings included: 1. […]

• No harm, potential for more than minimal, widespreadF886Aug 30, 2022

  Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with CDC (Centers for Disease Control) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements affecting 28 staff (24 agency staff and Staff #2, #3, #6, and #8) and all Residents. The findings included: 1. The facility staff failed to conduct routine and outbreak COVID-19 testing of all 24 agency/contract staff who worked in the facility June-August 2022. On 8/25/22, Surveyor B used the as-worked schedule and staff vaccination matrix to select a staff sample, which was reviewed for COVID immunization and testing. On 8/25/22 at approximately 10 AM, Surveyor B met with the facility's infection preventionist. […]