Ahc Of Lakewood, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure one (#8) of five residents received treatment and care in accordance with professional standards of practice out of 35 sample residents.Specifically, the facility failed to:-Ensure Resident #8's blood sugar levels were being monitored consistently per physician's orders; and,-Ensure the physician was notified, per physician's orders, when Resident #8's blood sugar levels were out of range.Findings include:I. Facility policy and procedureThe Blood Glucose Testing policy and procedure, dated 9/11/23, was provided by the nursing home administrator (NHA) on 3/23/26 at 12:53 p.m. The policy read in pertinent part, Blood glucose testing will be performed by a licensed nurse or nursing assistant per physician order. Appropriate infection control practices will be utilized by staff when performing blood glucose. Knock and gain permission before entering the resident's room. Verify the identity of the resident. Identify yourself and ask the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%).Specifically the facility's medication error rate was 6.5%, or three errors out of 31 opportunities.Findings include:I. Facility policy and procedureThe Administration of Medication policy and procedure, dated 5/5/26, was provided by the nursing home administrator (NHA) on 3/23/26 at 12:53 p.m. The policy read in pertinent part, Licensed personnel, in accordance with professional standards of practice, will appropriately administer prescribed medications. Compare the prescription label to the order on the electronic medication administration record (eMAR). Verify the six medication administration rights: right patient, right drug, right dose, right dosage form, right route, right time.II. ObservationsOn 3/18/26 at approximately 8:20 a.m. licensed practical nurse (LPN) #1 was preparing to administer a lidocaine (topical medication used to treat pain) 4% patch to Resident #19. Review of Resident #19's March 2026 computerized physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to maintain accurately documented medical records for one (#45) of two residents reviewed out of 35 sample residents.Specifically, the facility failed to ensure the administration of Resident #45's as needed (PRN) hydromorphone (opioid analgesic used to treat moderate-to-severe pain when other options are inadequate) on 3/12/26 and 3/13/26 was documented in the resident's electronic medication administration record (eMAR).Findings include:I. Facility policy and procedureThe Administration of Medication policy, updated 5/5/25, was provided by the nursing home administrator (NHA) on 3/23/26 at 1:59 p.m. It read in pertinent part, Licensed personnel, in accordance with professional standards of practice, will appropriately administer prescribed medications. Identify each resident before administering any medication. Use picture identification located in the resident's eMAR and/or verify by asking the resident to state his/her full name,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included the use of an electronic elopement prevention system, dialysis services and hospice services. Findings include: I. Record review The facility assessment was provided by the nursing home administrator (NHA) on 12/19/23 at 11:27 a.m. The facility assessment was last reviewed on 10/17/23 by the NHA, director of nurses (DON) and the interdisciplinary team (IDT). The facility assessment failed to include the following: -The facility had an electronic elopement prevention system. -The facility offered contracted dialysis and hospice services. II. Interview The NHA was interviewed on 12/19/23 at 11:41 a.m. He said he was not aware the services identified were not included in the facility assessment. He said the facility assessment should be a reflection of all the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews for three of five certified nurse aides (CNAs) reviewed. Specifically, the facility had not provided inservice education based on the outcome of the performance reviews for CNA #1, #2 and #4. Findings include: I. Record review CNA #1 (hired 8/10/22) had a performance review on 11/10/23. CNA #2 (hired 8/10/22) had a performance review on 11/11/23. CNA #4 (hired 8/10/22) had a performance review on 8/10/23. -The CNAs did not have an inservice education plan based on the outcome of the review. II. Interview The director of nursing (DON) was interviewed on 12/21/23 at 9:45 a.m. She said the facility had completed the annual performance reviews, but was not aware the performance reviews needed to develop regular inservice education based on the outcome of the performance reviews. She said the facility would develop a plan to complete the performance reviews going…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to honor resident choices for two (#22 and #94) of three residents reviewed for showers out of 21 sample residents. Specifically, the facility failed to ensure Resident #22 and Resident #94 received two showers a week and identified on the baseline care plan. Findings include: I. Resident #22 A. Resident status Resident #22, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included chronic kidney disease, end stage renal disease and type II diabetes mellitus. The 12/9/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. She had no behaviors or rejections of care. The assessment identified dialysis care. B. Record review The care plan, initiated 12/18/23, identified ADL functional status and rehabilitation potential. Interventions included staff to assist with showers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one (#22) of three residents out of 21 sample residents. Specifically, the facility failed to develop a person-centered baseline care plan for Resident #22 that included dialysis care and services. Findings include: I. Facility policy The Baseline Person Centered Care Plan policy, revised 9/11/23, provided by the director of nursing (DON) on 12/21/23 at 9:02 a.m. included: The baseline person centered care plan is developed during the admission process to direct patient care prior to the development of the comprehensive care plan. The baseline person centered care plan is written to include care to be given, goals to be accomplished, and actions necessary to attain the goals. This form covers the basic information utilized to disseminate information to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#242) resident reviewed for discharge planning out of 21 sample residents. Specifically, the facility failed to ensure the discharge planning process was developed, communicated and documented in Resident #242's medical records. Findings include: I. Resident status Resident #242, age [AGE], was admitted on [DATE]. According to the December 2023 computerized physician order (CPO), diagnoses included hypertension, cellulitis (skin infection) of right arm, spondylosis (abnormal wear on the cartilage and bones of the neck), heart disease with heart failure, type two diabetes mellitus with diabetic neuropathy, hyperlipidemia, sleep apnea, atrial fibrillation, anemia, depression, insomnia, weakness and fall. The 12/13/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. The resident required limited one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#242) of five residents reviewed for medication errors of 21 sample residents. Specifically, the facility failed to ensure that Resident #242 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include: I. Professional reference According to the Lantus (glargine) manufacturer guidelines, updated 2022, retrieved from https://www.lantus.com/dam/jcr:817aed9c-a677-4cd6-a6b3-d93d8aba629a/lantus-solostar-pen-guide.pdf on 12/28/23 included the following recommendations, Perform a safety test. Dial a test dose of two units. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in one out of one units. Specifically, the facility failed to: -Ensure an intravenous (IV) administration set was stored in a sanitary manner; and, -Ensure the hub of an insulin pen was cleaned off prior to the administration of insulin Findings include: I. Professional reference [NAME], J., [NAME]. B. (August 2022). Enhancing Peripheral Line Maintenance Practices Among Nurses in a Critical Care Setting: A Quality Improvement Project. University of New Hampshire. https://scholars.unh.edu/cgi/viewcontent.cgi?article=1700&context=honors, retrieved on 1/2/24. The Institute for Safe Medication Practices (ISMP) has identified that there are two common practices that continue to put patients at risk for infection including 1) failure to place a sterile cap on the end of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.