Inspection Results » Lake Forest Nursing Center

Health Inspection on May 18, 2018 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-09-09)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (Corrected 2018-07-12)
   • Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. (Corrected 2018-09-09)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-09-09)
   • Provide and implement an infection prevention and control program. (Corrected 2018-07-12)
   • Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. (Corrected 2018-08-27)
   • Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (Corrected 2018-08-27)
   • Keep all essential equipment working safely. (Corrected 2018-08-27)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide activities to meet all resident's needs. (Corrected 2018-07-12)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-07-12)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne (Corrected 2018-08-27)
   • Have a plan that describes the process for conducting QAPI and QAA activities. (Corrected 2018-08-27)
   • Respond appropriately to all alleged violations. (Corrected 2018-07-12)
   • Provide for the safe, appropriate administration of IV fluids for a resident when needed. (Corrected 2018-08-27)
   • Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. (Corrected 2018-07-12)
   • Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. (Corrected 2018-07-12)
   • Ensure that residents are free from significant medication errors. (Corrected 2018-07-12)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-07-12)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-08-27)
   • Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install (Corrected 2018-07-12)
   • Provide routine and 24-hour emergency dental care for each resident. (Corrected 2018-08-27)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2018-07-12)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-07-12)
   • Allow residents to self-administer drugs if determined clinically appropriate. (Corrected 2018-07-12)
   • Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. (Corrected 2018-07-12)
   • Implement a program that monitors antibiotic use. (Corrected 2018-08-27)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-09-09)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-07-12)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-07-12)
   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2018-08-27)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-08-27)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-08-27)
   • Provide timely, quality laboratory services/tests to meet the needs of residents. (Corrected 2018-08-27)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-07-12)
   • Ensure meals and snacks are served at times in accordance with residentÂ’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of schedu (Corrected 2018-09-09)
   • Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. (Corrected 2018-07-12)

5. Pattern: No actual harm with potential for minimal harm

   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-09-09)
   • Provide special eating equipment and utensils for residents who need them and appropriate assistance. (Corrected 2018-09-09)