Lakewood Villa

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Egress Deficiencies

Have exits that are accessible at all times.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Based on record review and interviews, the facility failed to ensure two (#1 and #2) of eight residents reviewed for abuse out of eight sample residents were free from abuse. Specifically, the facility failed to ensure Resident #1 and Resident #2 were free from abuse by each other. Findings include: I. Facility policy and procedure .. *** CITATION TEXT NOT FOUND *** A survey for Incident #40204 was conducted on 7/7/25. One deficiency was 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 complaint survey, prompted by #CO39217 and Incident #39384, Incident #39405, Incident #39406 and Incident #39426 was completed on 3/17/25 to 3/25/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure four (#2, #3, #6 and #9) of nine residents reviewed for abuse out of 13 sample residents were kept free from abuse. Specifically, the facility failed to:-Protect Resident #2 from physical abuse by Resident #3;-Protect Resident #6 and Resident #3 from physical abuse from each other; and, -Protect Resident #9 from physical abuse by Resident #3. Findings include: I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation policy and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 3/24/25 at 2:00 p.m. The policy read in pertinent part, "Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. "The resident abuse program consists of a facility-wide commitment and resource allocation to support protecting residents from abuse by:-Developing and implementing policies and protocols to prevent and identify abuse, neglect and exploitation, ensure adequate staffing and oversight to prevent burnout, stressful working situations and high turnover rates;-Conduct employee background checks;-Establishing and maintaining a culture of compassion and caring for all residents;-Providing staff education and training on abuse;-Implementing measures to address factors that lead to abuse;-Identifying and investigating all possible incidents of abuse;-Protecting residents from further harm during investigations; -Reviewing allegations of abuse during monthly quality assurance and performance improvement (QAPI) meetings; and,-Involving the resident council in monitoring and evaluating the facility' s abuse prevention program." II. Facility investigations of abuse incidentsA. Incident of physical abuse by Resident #3 towards Resident #2 on 2/13/25The 2/13/25 abuse investigation report was provided by the clinical resource nurse (CRN) on 3/24/25 at 9:50 a.m. It documented there was a witnessed, physical altercation between two residents (Resident #2 and Resident #3)..

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on January 13, 2025 for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies."This structure is a one (1) story, Type II (000).. Through documentation review, it was determined that the facility failed to meet the Fire Drill requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) The fire drill documentation consisted of the following dates and times.12/31/2024 the documentation stated it was for the second shift, however no times were listed. The documentation did not comply with the requirements of the code, only a staff log sheet was provide.. Through observation during the survey and documentation review, it was determined that the facility failed to meet the Emergency Lighting requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) Emergency lighting documentation was provided on the following dates. 01/2025, 12/2024, 11/2024, 10/2024, 09/2024, 08/2024, 07/2024, 06/2024. Additionally, one inspection page was provided, with a full calendar year liste.. Through observation during the survey and documentation review, it was determined that the facility failed to meet the HVAC requirements in accordance with NFPA 10. This STANDARD is not met, as evidenced by: 1) Through documentation review it was determined there was no damper inspection as the facility was under the impression that no fire dampers existed.2) During the tour of the facility, it was determined that there is a fire damper in the laundr.. Through observation during the survey and interview, it was determined that the facility failed to meet the Smoking Regulation requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) During the facility tour, while outside in the smoking area, there was no metal container with a self-closing cover to dump the ashes into. The administrator was interviewed on how the existing ashtrays were emptied, the administrator answere.. Through observation during the survey, it was determined that the facility failed to meet the Corridor - Doors requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) The door to room 14 had a too-large gap and would not resist the passage of smoke. 2) The door to room 36 had the striker plate missing, which positively latches the door in place. Without this striker plate, the door could not resist the passage of smoke .. Through observation during the survey, it was determined that the facility failed to meet the Discharge from Exits requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) During the tour of the facility, the Back Unit Courtyard Exit was not clear of obstructions and did not provide an unobstructed path to the public way. Items including garden hoses, garden hose reels, raised garden beds, and topsoil on the sidewalks either .. Through observation during the survey, it was determined that the facility failed to meet the Portable Fire Extinguishers requirements in accordance with NFPA 10. This STANDARD is not met, as evidenced by: 1) During the tour of the facility, many fire extinguishers were mounted too high above the finished floor. The facility shall audit all locations, however the following areas were specifically noted. Dining Room, Extinguisher near room 36,Life Safety C.. Through observation during the survey, it was determined that the facility failed to meet the Utilities – Gas and Electric requirements in accordance with NFPA 101. This STANDARD is not met, as evidenced by: 1) The Laundry room had an electrical subpanel. When the subpanel was opened, blanks or breakers were missing. In one area, black electrical tape was used in lieu of a blank. 2) The laundry room water heater had the cover for all the electrical com..

A recertification survey with complaint #CO36350, #CO37802 and #CO38553 was conducted on 12/16/24 to 12/19/24. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 12/16/24 to 12/19/24. No deficiencies were cited. Based on interviews and record review, the facility failed to protect and keep residents safe from physical abuse for one (#37) of three residents reviewed for physical abuse out of 29 sample residents.Specifically, the facility failed to protect Resident #37 from physical abuse by a staff member.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy and procedure, revised September 2022, was received from the nursing home administrator (NHA) on 12/23/24 at 11:00 a.m. It revealed in pertinent pa.. Based on observations and interviews, 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 diseases and infection.Specifically, the facility failed to:-Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touched areas (call lights, door handles and handrails);-Ensure housekeeping staff used the correct surface disinfectant products; -Ensure enhanced barrier preca.. Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one resident (#3) out of 29 sample residents. Specifically the facility failed to ensure insulin pens were primed prior to medication administration for Residents #3. Cross-reference F759 failure to ensure the medication error rate was less than five percent (%). Findings include:I. Professional referenceAccording to the Instructions for use Humalin R KwikPen, retrieved 12/26/24 from: https://pi.lilly.com/ca/humulin-n-r-ca-ifu-kp.pdf I.. 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 referenceThe Colorado Retail Food Establishment Rules and Regulations, revised March 2024, r.. Based on observations, record review and interviews, the facility failed to ensure that its medication error rate was less than five percent (%).Specifically, the facility had a medication error rate of 6.45%, which was two errors out of 31 opportunities for error. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed., E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment."Profe..

A complaint survey, prompted by #CO34989 and Incident #35505 was completed on 4/25/24 to 5/1/24. One deficiency was cited. 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.Resident #1, diagnosed with schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), unsteadiness on feet, restlessness and agitation and need for supervision, eloped from the facility on 12/24/23 at approximately 10:11 p.m. when he exited the facility through an alarmed dining room door and an outside gate which was unlocked. Facility staff were unaware Resident #1 was missing until agency certified nurse aide (ACNA) #1 returned to the facility from break at approximately 10:44 p.m. (33 minutes later) and observed the resident seated on the ground in the snow and stuck in an orange construction site fence (a safety barrier, lightweight fence) that separated the facility property from nearby construction. Resident #1 was brought back into the facility by staff and assessed by registered nurse (RN) #1. RN #1 encountered difficulties with obtaining the resident' s vital signs and the resident was transported to the hospital for further evaluation shortly thereafter where the resident was diagnosed with right lower extremity frostbite. Resident #1 did not return to the facility per family request. The facility began investigating the incident on 12/27/24 (three days after the resident eloped) and determined Resident #1 eloped from the facility due to the staff' s failure to respond to the sound of the dining room door alarm.The facility responded by providing education to the facility staf..