Lakewood Villa

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 1, 2024

  Based on observations, interviews, and record review, the facility failed to ensure two (#1 and #2) out of five sample residents at risk for elopement, received adequate supervision and facility assistive devices to prevent elopement. Specifically, the facility failed to provide Resident #1 and Resident #2 the supervision necessary to prevent elopements. These facility failures created a situation with serious harm and a situation with the likelihood of serious harm to residents' health and safety if not immediately corrected. […]

• Actual harm, isolatedF689Jul 17, 2023

  Based on observations, record review and interviews the facility failed to ensure three (#29, #18 and #25) of seven residents reviewed for accidents out of 27 sample residents received adequate supervision to prevent accidents. Resident #29, who was at fall risk, sustained 14 falls over six months. The facility failed to determine the root cause of the falls and failed to implement effective fall interventions. Resident #29 had an unwitnessed fall on 2/17/23 and had a clavicle (collarbone) fracture confirmed three days later from the fall. She was sent to the hospital for evaluation and treatment and returned to the facility on [DATE]. Resident #29 sustained nine additional falls after the fall with fracture. […]

• Actual harm, isolatedF692Jul 17, 2023

  Based on record review and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for two (#25 and #27) of five residents out of 27 sample residents. Resident #25, who was known to be at risk for weight loss due to hemiplegia (paralysis of one side of the body), dementia and dysphagia (difficulty with swallowing), experienced a choking episode on 3/27/23. […]

• No harm, potential for more than minimal, widespreadF812Dec 19, 2024

  Based on observations, record review and interviews, the facility failed to ensure food items were stored, prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to have a system in place to monitor the internal water temperature and concentration (parts per million-ppm) of hypochlorite of the dish machine in the main kitchen to ensure tableware, drinkware and cookware were effectively sanitized. Findings include: I. Professional reference The Colorado Retail Food Establishment Rules and Regulations, revised March 2024, retrieved on 12/26/24, read in pertinent part: A test kit or other device that accurately measures the concentration in MG/L (milligrams per liter) of sanitizing solutions shall be provided. […]

• No harm, potential for more than minimal, widespreadF925Jan 25, 2024

  Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to: -Take the appropriate measures to control a mice problem in the facility including failing to eliminate or minimize food sources; and, -Attempt to eliminate the mice from entering the facility through door gaps and holes. Findings include: I. Professional reference According to the Center for Disease Control (CDC) revised July 2019 Guidelines for Environmental Infection Control in Health-Care Facilities, retrieved from:https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html Mice are among the typical pest populations found in health-care facilities. […]