Lakewood Post Acute and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Lakewood Post Acute and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF692Sep 28, 2023

  Based on record review, observations and staff interviews, the facility failed to ensure one (#6) of three residents reviewed out of 28 sample residents, was provided the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #6, age 76, was admitted on [DATE] with diagnoses of fractured right femur (thigh bone), NPO (no food or fluids by mouth), type two diabetes, anemia, dysphagia (difficulty swallowing), and vitamin D deficiency. Resident #6 sustained a weight loss of 7.7 % (8.3 lbs) from 8/22/23 to 9/12/23, and a weight loss of 11.6 % ( 12.0 lbs) from 8/22/23 to 9/19/23, which was considered significant. Resident #6's weight was not obtained on 9/26/23, and not requested on 9/27/23 or 9/28/23. […]

• Actual harm, isolatedF697Sep 28, 2023

  Based on record review and interviews, the facility failed to consistently provide pain management services for one (#14) of one resident reviewed for pain out of 28 sample residents. Resident #14 was admitted on [DATE]. He had a surgical procedure on 9/25/23 to scrape infected bone out of his left foot and ankle region as a result of osteomyelitis (bone infection). Resident #14 had pain from the recent surgical procedure and phantom pain from a previous right leg above-knee amputation. He had orders for as-needed (PRN) Oxycodone which relieved his pain when given, but it was not administered in a timely manner. The facility failed to ensure Resident #14 had enough pain medication on hand to manage his pain and when it ran out failed to provide it from the facility emergency kit. […]

• Actual harm, isolatedF684Apr 19, 2023

  Based on record review and staff interviews, the facility failed to ensure one (#1) resident reviewed out of nine sample residents received treatment and care in accordance with professional standards of practice. The facility failed to consistently monitor the blood sugar for Resident #1 as written in the provider's orders. The facility failed to notify the provider for the change in condition. Resident #1 sustained blood sugar was below the normal range multiple times on 1/10/23. Record review revealed that the diabetic interventions were not implemented and the provider was not notified to modify the plan of care to prevent further complications. Findings include: I. […]

• Actual harm, isolatedF550May 27, 2021

  Based on record review and interviews, the facility failed to ensure the right to be treated with respect and dignity for one (#4) of five sample residents. The facility failed to ensure Resident #4 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by an incident that occured on 5/10/2021 were Resident #4 was treated in an undignified manner by registered nurse (RN) #4. Because of this treatment, Resident #4 said she felt, belittled, worthless, and crazy which triggered her [CONDITION(S)]. Findings include: I. Facility policy and procedure The Resident Rights policy, revised 3/1/18, was provided electronically by the nursing home administrator on 5/19/21. […]

• Actual harm, isolatedF689May 27, 2021

  Based on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance to prevent accidents for one (#2) of five sample residents. Specifically, the facility failed to ensure the resident was transferred by two staff members appropriately to prevent a humerus fracture which caused the resident pain and changed her transfer status from a two person assist to a full mechanical lift. Findings include: I. Facility policy and procedure The Accidents/Incidents policy, revised 11/28/16, was provided electronically by the nursing home administrator (NHA) on 5/19/21. […]