Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeview Village during CMS and state inspections, most recent first.
Unsanitary Food Storage and Kitchen Conditions: Surveyors observed multiple food safety and sanitation issues in the kitchen and satellite food areas, including trash cans without lids, missing foot-activated trash cans at the hand-washing station, undated and open food items in the refrigerator and freezer, a dented can in dry storage, food particles and dust in cabinets, and residue behind and on a soda machine. The Dietary Director stated staff needed to step up their game, and the facility policy required sanitary food prep areas and properly dated, labeled, and sealed refrigerated food.
A resident was transferred to the hospital, and although the Notice of Transfer form was documented as provided to the resident and representative, the EMR lacked evidence that the bed hold policy with the facility’s per diem rate was given. Admin staff confirmed the policy was not provided because the resident was on skilled services, despite the facility policy requiring residents or representatives to be informed before transfer and contacted afterward.
Care Plan Missing Nail Care Intervention: A resident with CVA, hemiparesis/hemiplegia, and severely impaired cognition required help with all ADLs, but the care plan did not include a nail care intervention. During observation, a black substance was seen under two fingernails on the resident’s right hand. Staff stated the Kardex is updated daily and the main care plans are updated from there, while the facility policy required the interdisciplinary team to develop care plans that include needed hygiene/ADL assistance.
Failure to provide ADL assistance included a resident with CVA-related hemiparesis and severely impaired cognition who required help with all ADLs and had a care plan directing staff to assist with ADLs. Staff observed black material under the resident’s fingernails on multiple occasions, and a CNA and LN stated her nails are to be cleaned every shift when dirty substance is present.
A resident with Alzheimer's disease, dementia, anemia, and PVD had a pressure-related wound and orders for a foot cradle and Prevalon boots while in bed. Staff observations showed the cradle and boots were not in place, and later the blankets were resting directly on both feet despite the ordered interventions. Nurses and a CNA stated the devices should have been used as ordered.
A resident with COPD, chronic respiratory failure, and mobility impairment had humidified O2 set up with the concentrator in the bathroom and about 30 feet of tubing strung across the room, with coils on the floor near his recliner. Another resident with severe cognitive impairment, impaired balance, and orders for staff-assisted mobility was observed ambulating alone with a 4WW in his room on multiple occasions while staff were nearby but not present with him.
A resident with anxiety and post-joint replacement care needs did not receive ordered clonazepam and Soma because the medications were not available. The MAR showed multiple missed doses, progress notes documented the meds were unavailable, and there was no documentation that the provider or pharmacy was contacted. The resident also had repeated high pain scores and reported that pain was not controlled and that staff were not giving pain medication as ordered.
Inaccurate posted nurse staffing information was observed near the nursing station. Review of staffing sheets showed missing scheduled hours on multiple sheets, and the resident census was absent on some sheets. An Administrative Nurse stated the unit floor nurse completed and posted the sheet before the next shift, and the facility policy required the DON or designee to ensure the daily RN, LPN, and CNA staffing schedule was posted at the entrance to each household.
A resident with severe cognitive impairment and a history of wandering triggered a WanderGuard alarm and exited through a stairwell. Staff responded to the alarm but did not immediately open the stairwell door to search, allowing the resident to leave the building and be found outside with injuries several minutes later. Staff interviews revealed confusion about alarm procedures, and the failure to provide adequate supervision and a thorough search led to the resident's elopement and injury.
The facility failed to store and prepare food items according to professional standards, risking foodborne illnesses. Observations revealed improperly stored and unlabeled food in freezers and refrigerators, and uncovered dishes in the clean dish storage area. Interviews with dietary staff indicated expectations for proper labeling and storage were not met, and facility policies were not adequately followed.
The facility failed to follow proper infection control standards, placing residents at risk for infectious diseases. Observations showed non-compliance with protocols, such as improper storage of nasal cannulas and catheter bags touching the floor. Staff did not consistently perform hand hygiene between glove changes during care procedures. Additionally, the facility lacked a comprehensive plan for Legionella prevention, as confirmed by staff interviews.
The facility failed to provide a system for residents to file grievances anonymously, as required by policy. An inspection revealed no labeled grievance boxes, and interviews with Resident Council members and staff indicated a lack of awareness and implementation of such a system. This deficiency placed residents at risk for decreased psychosocial well-being.
A facility failed to implement pressure-reducing interventions for a resident at risk for pressure ulcers. The resident, with multiple health conditions and severely impaired cognition, was observed without required heel protector boots in place, contrary to the care plan. Staff interviews confirmed the responsibility to ensure special equipment was used, but the necessary interventions were not implemented, risking skin breakdown.
A cognitively impaired resident with multiple medical conditions experienced numerous falls due to the facility's failure to implement appropriate, resident-centered interventions. Despite having a care plan with various measures, the interventions were not effectively tailored to the resident's needs, resulting in continued falls without injury. Staff interviews indicated that the interventions were not person-centered, and the facility's fall prevention protocol was not adequately followed.
The facility failed to provide adequate incontinence and catheter care for two residents, leading to a risk of UTIs. A resident with a history of UTIs received improper perineal care, with staff not performing hand hygiene between glove changes and using the same wipe multiple times. Another resident with a Foley catheter did not receive proper hand hygiene during a urinary leg bag change. These deficiencies in care practices increased the risk of infection for both residents.
A resident with pulmonary fibrosis and CHF had their nasal cannula improperly stored on the floor, contrary to facility policy requiring sanitary storage in a bag. This oversight increased the risk of respiratory infection, as confirmed by staff interviews.
A facility failed to document a risk assessment and obtain informed consent for the use of side rails for a resident with Alzheimer's and cognitive impairment. The resident's care plan included bed canes for assistance, but no safety assessment or consent was documented, placing the resident at risk for uninformed decisions and impaired safety.
The facility failed to document appropriate rationale and nonpharmacological intervention attempts for antipsychotic medication use in two residents with dementia. Despite policies requiring such documentation, records lacked physician-documented rationale and risk-benefit assessments. Observations and staff interviews indicated that dementia was not an appropriate indication for antipsychotic use, placing residents at risk for unnecessary medication and complications.
A facility failed to maintain consistent communication with a hospice provider for a resident receiving hospice services. The resident, with a history of cerebral atherosclerosis, kidney disease, dementia, and diabetes mellitus, required assistance with ADLs and mobility. The care plan lacked specific directions for collaboration with the hospice provider, and the EMR did not consistently document care collaboration from January to May 2024. This deficiency placed the resident at risk for delayed services, potentially affecting her well-being.
The facility failed to document consent or declination for the PCV20 vaccine for two residents, despite their history of refusing pneumococcal vaccinations. This lack of documentation was identified during a survey and placed the residents at increased risk for pneumonia-related complications. The facility's policy requires offering the vaccine and documenting the decision, but this was not adhered to for these residents.
Unsanitary Food Storage and Kitchen Conditions
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. During the initial tour of the main kitchen, surveyors observed that the kitchen did not have foot-activated trash cans by the hand-washing station, and four trash cans did not have lids. In the kitchen refrigerator, two bags of diced onions were found without a date, and one bag was open to air. In the freezer, one bag of hash browns was left open, and in dry storage one can of prunes had a dent. Additional observations showed similar sanitation issues in other food service areas. In the second-floor rehabilitation refrigerator, one box of hamburger patties was left open to air, and food particles were seen in cabinet drawers along with dust or dirt in the grooves of the cabinet doors. In the third-floor rehabilitation kitchen, one bag of biscuits in the freezer was observed with a brown substance in the bottom of the freezer, and dried food particles and dust were seen in cabinet crevices. In the second-floor satellite kitchen on the LTC unit, a white food substance was observed behind the soda machine, and soda syrup was seen on the sides of the machine. The Dietary Director stated that staff needed to step up their game. The facility policy required a clean, sanitary, and safe food preparation area and stated that prepared food stored in the refrigerator until service must be dated, labeled, and tightly sealed.
Failure to Provide Bed Hold Policy at Transfer
Penalty
Summary
The facility failed to ensure Resident 143 and the resident’s representative were provided with the bed hold policy, including the facility’s per diem rate to hold a bed, when the resident was transferred to the hospital. Resident 143’s EMR showed admission to the facility on 01/27/26 and a Notice of Transfer form dated 02/02/26 documenting that the resident was sent to the hospital and that the form was provided to the resident and representative. However, the EMR lacked evidence that the bed hold policy was provided, and the facility was unable to produce documentation showing it had been given at the time of transfer. Administrative Staff A confirmed on 04/22/26 that the bed hold policy was not provided because the resident was on skilled services. The facility’s Bed Holds and Return to Facility policy stated residents or representatives would be informed before transfer to a hospital or therapeutic leave of the bed hold policy, and that the social worker would mail a notice and contact the resident and representative the next business day.
Care Plan Missing Nail Care Intervention
Penalty
Summary
The facility failed to update Resident 3’s care plan for ADL assistance. Resident 3 had a diagnosis of cerebral infarction with hemiparesis/hemiplegia, and the Quarterly MDS showed a BIMS score of 3, indicating severely impaired cognition, with a need for assistance with all ADLs. The care plan dated 10/08/25 identified an impaired ability to care for herself and directed staff to help with ADLs, but it did not include an intervention for nail care. During observation on 04/20/26 at 09:10 AM, Resident 3’s right hand was noted to have a black substance under two of the five fingernails. Administrative Staff A stated on 04/23/26 at 10:18 AM that the facility updates the Kardex daily and then staff update the main care plans from there. The facility policy stated that the interdisciplinary team develops the resident’s care plan and that the care plan includes when residents need assistance with hygiene/ADL care.
Failure to Provide Fingernail Hygiene Assistance
Penalty
Summary
The facility failed to provide ADL assistance for a resident with cerebral infarction with hemiparesis/hemiplegia and severely impaired cognition, who required assistance with all ADLs. Her care plan directed staff to help her perform ADLs, and the record noted she had an impaired ability to care for herself. During observation, her right hand was found with a black substance under two of the five fingernails on 04/20/26 and again on 04/21/26. On 04/22/26, staff were observed preparing the resident for a shower, which she received from hospice on Wednesdays and Fridays. Later that morning, the black substance under the fingernails had been removed, but a brown stain remained under two of the five fingernails. A CNA stated that nail care staff are to clean her nails every shift and that she tends to ding in her brief, which causes material to get under her fingernails. An LN also stated her fingernails are to be cleaned every shift and that staff are expected to clean them whenever there is a dirty substance under them.
Failure to Use Ordered Foot Cradle and Prevalon Boots
Penalty
Summary
The facility failed to ensure staff implemented ordered interventions to promote wound healing for a resident with Alzheimer's disease, dementia, anemia, and peripheral vascular disease. The resident's EHR, MDS, care plan, and CNA Kardex documented that she had a pressure-ulcer risk and was to use a foot cradle to keep blankets from touching her feet and Prevalon boots while in bed. Her record also included a 04/08/26 arterial doppler showing occlusion in both lower extremities with findings suggesting severe PVD, and wound documentation identified the right lateral foot wound as an arterial ulcer and Stage 3. Observations showed the ordered devices were not in place as directed. On 04/21/26 at 07:43 AM, the blanket cradle was on the floor next to the bed and the Prevalon boots were on the floor next to the dresser, with neither boot applied to either foot. Later that morning, the blanket cradle was in place, but the blankets had sunk down in the middle of the frame and were resting directly on both feet. Administrative Nurse F and CNA P stated the blanket cradle and Prevalon boots should be in place when the resident was in bed, and Administrative Nurse D stated staff should have followed the wound interventions and orders that were in place.
Unsafe oxygen tubing setup and unsupervised ambulation
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for a resident with chronic respiratory failure with hypoxia, COPD, heart failure, muscle weakness, lack of coordination, and abnormalities of gait and mobility. The resident’s MDS documented intact cognition, use of a wheelchair, need for assistance with multiple ADLs, shortness of breath with exertion, and receipt of oxygen therapy. His care plan directed staff to assist with transfers, keep personal items within reach, and provide oxygen as ordered. On observation, the resident wore humidified oxygen, but the oxygen concentrator was placed in the bathroom and approximately 30 feet of tubing was strung across the room to his chair, with several coils of tubing on the floor next to his recliner where he was sitting. Staff statements showed differing understanding of the oxygen setup. A CNA stated the concentrator should have been placed as close to the resident as possible and the tubing should not have been strung across the room. The resident stated the concentrator had remained in the bathroom and had never been moved. An LN stated the concentrator should have been as close to the resident as possible and that the shortest length of tubing possible should be used to prevent tripping hazards. An Administrative Nurse stated it was appropriate for oxygen tubing to be strung throughout the room and that the concentrator could be placed in another room as a method to help wean the resident off oxygen, while also stating that the shortest length of tubing possible, no more than approximately nine feet, was expected. The facility also failed to ensure adequate supervision for a resident with severe cognitive impairment, impaired balance, and a history of needing assistance with transfers and ambulation. The resident’s MDS documented a BIMS score of six, use of a walker and wheelchair, and need for staff assistance with several ADLs. His falls assessment identified impaired balance and need for assistance and support during transfers and gait, and his care plan and Kardex identified him as a one-person assist for transfers and mobility. Despite this, he was observed ambulating alone in his room with a 4WW on multiple occasions, including walking from his recliner to the bathroom and across the room without staff present, while staff were in the hall or walked by his room. Staff interviews reflected uncertainty about his ambulation needs, while another staff member stated he required contact guard assistance with all ambulation and was impulsive.
Failure to Provide Ordered Medications Due to Unavailable Supply
Penalty
Summary
The facility failed to provide a resident’s physician-ordered medications because the medications were not available. The resident had diagnoses including anxiety and aftercare following joint replacement surgery, and the admission care plan directed staff to assess pain, give pain medications as ordered, and monitor behavior concerns or anxiety. Physician orders included clonazepam 1 mg at bedtime for anxiety and Soma 350 mg at bedtime for muscle pain, later changed to as needed. The electronic MAR showed the resident did not receive clonazepam on three consecutive days and did not receive Soma on two days. Progress notes documented that both medications were not available, but there was no documentation that the provider was notified or that the pharmacy was contacted to obtain the missed medications. The resident’s record also documented repeated reports of significant pain, including ratings of 10, 7, 9, and 10 on the 0-10 scale over several days. On one occasion, the resident was anxious and fidgeting in bed and stated her pain was not controlled and that staff were not correctly giving her pain medication as ordered. Staff interviews indicated that if a medication was unavailable, the nurse would check Cubex and notify the nurse if it was not there, and administrative staff stated medications should be available within 24 hours of admission or orders and that nurses should follow up with the pharmacy if medications did not arrive. The pharmacy contract stated routine and emergency pharmacy services were available, with emergency medications within four hours and other medications provided as soon as possible or by the next routine delivery.
Inaccurate Posted Nurse Staffing Information
Penalty
Summary
The facility failed to display accurate and identifiable posted nurse staffing information. On observation, a daily staffing sheet was hanging on the wall near the nursing station on the first floor. Review of the Daily Nursing Staffing Information sheets from 07/04/25, 12/02/26, 03/05/26, and 04/21/26 showed that the sheets lacked the scheduled hours, and the resident census was missing from the daily nursing staffing information sheets on 12/02/26 and 03/05/26. During interview, Administrative Nurse D stated that the floor nurse assigned to each unit would complete the posted staffing sheet for that unit and post it before the upcoming shift, and that the sheet was supposed to include the facility name, date, current census, and actual hours worked for nurses, CNAs, and CMAs, although she was unsure whether total hours were required. The facility’s posting daily nurse staffing policy, procedure 01.01.10, stated that the DON or designee would ensure the number of RNs, LPNs, and CNAs scheduled for each day is posted at the entrance to each household.
Failure to Provide Adequate Supervision and Thorough Search Following WanderGuard Alert
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and a thorough search in response to a WanderGuard alert for a resident with severe cognitive impairment and a high risk for elopement. The resident, who had diagnoses including Alzheimer's disease, dementia, and a history of wandering, was wearing a WanderGuard bracelet and was known to be independent with ambulation but required assistance with activities of daily living. On the day of the incident, the resident triggered the WanderGuard alarm by exiting through a stairwell door, but staff did not immediately open the door to search the staircase where the alert sounded. Camera footage and staff interviews revealed that although staff responded to the alarm within 36 seconds, they did not check the stairwell immediately and instead began searching other areas. The resident was able to exit the building through the stairwell, walk around the sidewalk at the back of the facility, and was eventually found on the ground near the parking lot approximately five to six minutes later. The resident sustained visible injuries, including a forehead abrasion and right ankle swelling, and was transported to the hospital for evaluation and treatment. The facility's policy required prompt and thorough investigation when a resident could not be located, but staff actions did not align with this expectation. Staff interviews indicated confusion about the alarm system and the appropriate response, with some staff not understanding the alarm codes or the need to open the door to the stairwell immediately. The failure to provide adequate supervision and to implement a thorough search in response to the WanderGuard alert resulted in the resident's elopement and injury, constituting immediate jeopardy.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The kitchen inspection revealed multiple instances of improper food storage, including opened bags of frozen food items such as carrots, hash browns, and chicken wings that were not closed, labeled, or dated. Additionally, the walk-in freezer and refrigerator contained unlabeled and undated food items, including blueberries, macaroni and cheese, and various leftovers. The cooler designated for leftover food had several containers of mashed potatoes, gravy, and chili that were not labeled or dated. Furthermore, the clean dish storage area had bowls and ramekins that were not covered or inverted, and the dry storage area had an opened bag of pecans that was not dated or sealed. Interviews with dietary staff revealed that there was an expectation for all opened food items to be wrapped, labeled, and dated before storage, and for dishes to be stored covered or upside down. However, these practices were not consistently followed, as evidenced by the observations. The facility's policies on food storage and maintaining a sanitary food preparation area were not adequately implemented, as they directed that food should be dated, labeled, and tightly sealed, and that dishes should be stored in a manner to prevent contamination. The failure to comply with these standards placed residents at risk for foodborne illnesses.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control standards, which placed residents at risk for complications related to infectious diseases. Observations revealed several instances of non-compliance with infection control protocols. For example, a resident's nasal cannula was found lying directly on the floor next to their bed, and soiled linen was placed on the floor. Another resident's catheter tubing and drainage bag were observed touching the floor, and the drainage bag was improperly hung, allowing it to touch the floor. Further observations highlighted lapses in hand hygiene practices among staff. A licensed nurse failed to perform hand hygiene between glove changes while assisting a resident with a urinary leg bag change. Similarly, a certified nurse aide did not perform hand hygiene between glove changes during peri-care, using the same wipe multiple times and placing wipes on potentially contaminated surfaces. These actions were contrary to the facility's policies, which emphasized the importance of hand hygiene and using clean wipes for each swipe during peri-care. Additionally, the facility lacked a comprehensive plan or risk assessment for monitoring and preventing Legionella disease, a significant oversight given the vulnerability of the resident population. Interviews with staff, including the facility's infection preventionist and administrative staff, confirmed the absence of a facility-specific risk assessment for Legionella. The facility's policies on infection control, catheter care, and storage of respiratory equipment were not consistently followed, contributing to the identified deficiencies.
Failure to Implement Anonymous Grievance System
Penalty
Summary
The facility failed to implement a system that allows residents and their representatives to file grievances anonymously, which is a requirement to honor residents' rights. During an inspection, it was observed that the facility had a suggestion box located in a walkway area that required a door code to access, and there were no labeled grievance boxes available. Interviews with Resident Council members revealed that they were unaware of how to file a grievance or if there was a way to file one anonymously. They reported that they typically turned their complaints into Social Services or had family members contact Social Services on their behalf. Further interviews with facility staff, including Administrative Staff A and Activity Staff Z, confirmed the absence of a grievance box. Administrative Staff A stated that grievances were filed via email, phone calls, or through social services, and believed residents knew how to file grievances since the facility received them. However, Activity Staff Z, who was new to the facility, was unaware of any grievance box or a method for filing anonymous grievances. The facility's policy, revised in 2018, stated that residents have the right to file grievances anonymously, but this was not effectively implemented, placing all residents at risk for decreased psychosocial well-being.
Failure to Implement Pressure-Reducing Interventions
Penalty
Summary
The facility failed to ensure that staff followed the intervention in place for pressure-reducing boots for Resident 14, who was at risk for pressure ulcer development due to mobility impairment and other health conditions. Resident 14's medical record documented diagnoses including Alzheimer's disease, atrial fibrillation, anxiety, depressive disorder, hypertension, and dysphagia. The resident was assessed as having severely impaired cognition and was identified as at risk for pressure ulcers. The care plan required the use of pressure-reducing devices, a turning or repositioning program, and heel protector boots when in bed. However, during an observation, it was noted that Resident 14 was lying in bed with heels directly on the mattress, and the boots were not in place, contrary to the care plan. Interviews with facility staff, including a CNA and licensed nurse, revealed that all nursing staff were responsible for ensuring that residents' special equipment or devices were in place. The facility's policy on pressure injury prevention and management emphasized the importance of implementing interventions such as elevating the heels off the bed surface. Despite this, the facility did not implement the necessary pressure-reducing interventions for Resident 14's heels, placing the resident at risk for complications associated with skin breakdown.
Failure to Implement Resident-Centered Fall Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate, resident-centered interventions to prevent falls for a cognitively impaired resident, identified as R96. R96 had a history of multiple medical conditions, including cerebrovascular accident, vascular dementia, congestive heart failure, chronic kidney disease, diabetes mellitus, and aphasia, which contributed to her severely impaired cognition and increased risk of falls. The resident's care plan documented various interventions, such as the use of nonskid footwear, a hi-low bed, perimeter mattress, and call lights, but these measures were not effectively tailored to her specific needs. Despite the interventions in place, R96 experienced numerous falls, both witnessed and unwitnessed, over several months. The falls were documented in nursing notes, with each incident followed by the addition of new interventions, such as adjusting the toileting schedule, providing printed worksheets, and encouraging participation in activities. However, these interventions were not sufficiently individualized or effective in preventing further falls, as evidenced by the continued occurrence of falls without injury. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, revealed that the interventions were not person-centered and that the facility's fall prevention and management protocol was not adequately followed. The interdisciplinary team was responsible for developing a care plan with interventions to reduce the risk of falls, but the facility failed to identify and implement appropriate measures for R96, placing her at risk for additional falls and injuries.
Inadequate Incontinence and Catheter Care Leads to UTI Risk
Penalty
Summary
The facility failed to provide necessary care and services related to incontinence and catheter care for two residents, R33 and R415, placing them at risk for urinary tract infections (UTIs) and related complications. R33, who had a history of UTIs, was observed receiving inadequate perineal care. Certified Nurse Aide (CNA) O did not perform hand hygiene between glove changes and used the same wipe multiple times during perineal care, contrary to the facility's policy. This improper technique could lead to contamination and increase the risk of infection for R33, who was frequently incontinent of urine and had a history of UTIs caused by bacteria such as E. coli and Enterococcus faecium. R415, who had a Foley catheter due to urinary retention, also received inadequate care. Licensed Nurse (LN) H failed to perform hand hygiene between glove changes while changing R415's urinary leg bag, which is a critical step in preventing infection. The facility's policy required catheter care to be provided daily and when there was a possibility of fecal incontinence, but LN H did not adhere to these guidelines. This oversight placed R415 at risk for catheter-related complications and further UTIs, especially since R415 was already being treated for a UTI. Interviews with staff, including CNA O, LN J, and Administrative Nurses D and E, revealed a lack of adherence to proper hand hygiene and infection control procedures. Despite the facility's policies and frequent hand hygiene education, staff did not consistently follow the required protocols, leading to the deficiencies observed in the care of R33 and R415. The facility's failure to ensure proper hand hygiene and perineal care practices contributed to the risk of UTIs and other complications for these residents.
Improper Storage of Oxygen Tubing
Penalty
Summary
The facility failed to ensure the proper storage of oxygen tubing for a resident, identified as R413, which led to a deficiency in respiratory care. R413's medical history included pulmonary fibrosis, a need for assistance with personal care, and congestive heart failure. The resident's care plan required monitoring for shortness of breath and administering medications as ordered. However, during an observation, it was noted that R413's nasal cannula was placed directly on the floor next to the resident's bed, which is against the facility's policy for storing oxygen equipment. Interviews with various nursing staff confirmed that oxygen equipment, such as nasal cannulas, should never be placed on the floor due to the risk of contamination and infection. The facility's policy, dated November 2021, stated that oxygen tubing should be stored in a bag when not in use. The failure to adhere to this policy placed R413 at an increased risk for respiratory infection and complications, as the unsanitary storage of the nasal cannula could lead to exposure and contamination.
Failure to Document Risk Assessment and Consent for Side Rails
Penalty
Summary
The facility failed to ensure that a resident, identified as R60, had a documented risk assessment and informed consent for the use of side rails. The resident's electronic medical record lacked evidence of a safety assessment for side rails prior to their installation. Additionally, there was no documentation indicating that the resident or their responsible party was informed of the risks and benefits associated with the use of side rails. This oversight placed the resident at risk for uninformed decisions and impaired safety. R60 had a history of Alzheimer's disease, cognitive impairment, and a previous non-injury fall. The resident's care plan included the use of bilateral bed canes to assist with transfers and repositioning in bed. Despite these documented needs, the facility did not conduct a proper assessment or obtain consent for the use of side rails, as required by their policy. Observations confirmed the presence of bed canes, and interviews with administrative staff revealed the absence of a safety assessment for R60.
Lack of Documentation for Antipsychotic Use in Dementia Patients
Penalty
Summary
The facility failed to ensure appropriate documentation and rationale for the use of antipsychotic medications for two residents, R71 and R96, both diagnosed with dementia. For R71, the facility's records lacked a physician-documented rationale that included multiple unsuccessful attempts at nonpharmacological interventions and an assessment of the risks versus benefits for the continued use of antipsychotic medication. Despite the facility's policy requiring such documentation, it was not provided upon request. Observations noted R71 sleeping in the common area, and interviews with staff revealed that dementia was not considered an appropriate indication for antipsychotic medication. Similarly, for R96, the facility's records did not contain a physician-documented rationale for the use of antipsychotic medication, nor did they document attempts at nonpharmacological interventions. R96 had a history of cerebrovascular accident, vascular dementia, and other health conditions, with a documented severely impaired cognition. The care plan for R96 included the use of psychotropic drugs and instructions for staff to monitor for adverse effects and attempt non-pharmaceutical approaches before administering medications. However, the necessary documentation to support the use of antipsychotic medication was missing. The facility's policy on monitoring residents on psychotropic drugs, revised in 2017, stated that psychotropic medications should only be administered when necessary to treat a specific, diagnosed, and documented condition, and when beneficial to the resident. The policy also emphasized the use of non-pharmacological approaches to minimize medication use. The lack of documentation and rationale for the use of antipsychotic medications for residents R71 and R96 placed them at risk for unnecessary medication and related complications.
Inadequate Communication with Hospice Provider
Penalty
Summary
The facility failed to ensure a consistent communication process between the facility and the hospice provider for Resident 5, who was receiving hospice services. The deficiency was identified through observation, record review, and interviews. Resident 5 had a history of cerebral atherosclerosis, kidney disease, dementia, and diabetes mellitus, and required assistance with activities of daily living (ADLs) and mobility. Despite receiving hospice services, the facility's care plan for Resident 5 lacked specific directions for collaboration with the hospice provider, including details on services, frequency of visits, medications, and equipment provided by hospice. The facility's electronic medical record (EMR) system did not consistently document the collaboration of care for Resident 5 from January 2024 through May 2024. Interviews with facility staff revealed that hospice providers had access to the EMR and were supposed to scan documentation after each visit, but this was not done consistently. The facility's Hospice Services policy required a written hospice agreement to include a communication process to ensure resident needs were met 24 hours a day. The failure to ensure proper collaboration and documentation placed Resident 5 at risk for delayed services, potentially affecting her mental and psychosocial well-being.
Failure to Document Pneumococcal Vaccine Consent or Declination
Penalty
Summary
The facility failed to obtain consent or declination for the Pneumococcal Conjugate Vaccine (PCV20) for two residents, identified as R53 and R71, during a review of their clinical records. The records lacked documentation indicating whether the vaccine was offered, declined, or previously administered. This oversight was identified during a survey that included a sample of 24 residents, with five specifically reviewed for immunizations. The absence of documentation placed these residents at an increased risk for complications related to pneumonia. During an interview, the facility's infection preventionist, Administrative Nurse E, acknowledged the lack of documentation for R53 and R71, despite their history of refusing pneumococcal vaccinations. The facility's policy, revised in December 2022, mandates offering the pneumococcal vaccine to all residents, with the decision documented as either consent or declination. However, the facility was unable to provide the necessary documentation for these two residents, indicating a failure to adhere to their own vaccination policy.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Lenexa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westchester Village Of Lenexa | 0.8 mi | ★★★★★ | 0 | 0 |
| Delmar Gardens Of Lenexa | 1.2 mi | ★★★★★ | 10 | 0 |
| Shawnee Gardens Healthcare & Rehab Center | 2.2 mi | ★★★★★ | 2 | 0 |
| Delmar Gardens Of Overland Park | 2.3 mi | ★★★★★ | 15 | 0 |
| Garden Terrace At Overland Park | 2.6 mi | ★★★★★ | 4 | 2 |
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