Lake View Commons LLC

A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 4/6/23. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey was completed on 4/6/23. Deficiencies were cited. Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#1-#3). (Cross-reference Q1514)Findings include:1. Residence PolicyThe residence' s Medication and Treatment Administration policy, dated 2/3/22, read, in part: "All medications and treatments will be administered with a provided order in a timely manner. If an order cannot be followed, the provider will be notified and the situation will be documented in the resident record...Timely administration of medications/treatments means the medication/treatment is administ.. Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) at least quarterly audited the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting three of three sample residents (#1-#3). (Cross-reference Q1468)Findings include:The residence' s Medication and Treatment Administration policy, dated 2/3/22, read, in part: "A consultant pharmacist will provide random observation of personnel responsible for medication administration. These observations include but are not inclusive .. Based on record review and interview, the residence failed to ensure there was a readily available roster of current residents, their room assignments and emergency contact information, along with a diagram showing room locations, affecting 46 current residents.Findings include:On 4/6/23 at 8:45 a.m., the administrator was asked to provide a resident roster according to the regulations. On 4/6/23 at 9:35 p.m., the administrator provided a list of residents and their room numbers. There was no emergency contact information listed or a diagram that showed room locations. On 4/6/23 at approximately 4:45 p.m., the administrator said she was not aware of the resident roster requirement, wh.. Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 46 current residents.Findings include:1. References a. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that' s useful in many emergencies, such as a heart attack or near drowning, in which someone' s breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressions. This hands-only CPR recommendation applies to bot.. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident' s condition changes from baseline status.12.10 Each resident care plan shall:(A) Be developed with input from the resident and the resident' s representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferenc..

A recertification survey was completed on 4/6/23. A deficiency was cited. Based on record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting three of three sample participants (residents) (#1-#3). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, require the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.The residence' s Medication and Treatment Administration policy, dated 2/3/22, read, in part: "All medications and treatments will be administered with a provided order in a timely manner. If an order cannot be followed, the provider will be notified and the situation will be documented in the resident record...Timely administration of medications/treatments means the medication/treatment is administered as close to the scheduled time as possible. 1 hour before or after the time scheduled. If unable, reasoning will be documented." a. Resident #1 was admitted to the residence on 9/22/22 with diagnoses that included Parkinson' s disease.A written practitioner' s order, dated 1/11/23, directed the residence to administer Carbidopa-Levodopa 25-100 milligram (mg) five times daily at 7:00 a.m., 10:00 a.m., 1:00 p.m., 4:00 p.m. and 7:00 p.m. However, the March and April 2023 electronic medication administration records (eMARs) for Resident #1 read the medication was administered late on the following days and times:3/4/23 at 11:53 a.m., 2:10 p.m. and 8:20 p.m.3/5/23 at 8:55 a.m. and 12:33 p.m.3/7/23 at 8:31 p.m.3/17/23 at 8:12 p.m.3/23/23 at 5:31 p.m.3/24/23 at 8:08 p.m.3/28 at 8:04 p.m.4/1/23 at 8:13 p.m.Progress notes for March 2023 in Resident #1' s record revealed that Resident #1 had unwitnessed falls on 3/5/23 at 3:02 a.m., 3/8/23 at 8:45 p.m., 3/24/23 at 2:15 p.m., and 3/25/23 at 6:23 a.m.InterviewsOn 4/6/23 at 4:08 p.m., a registered ..