Lakeview Lodge

Ensure hazardous items are locked and not unattended

Based on observation and interview, the licensee did not ensure that sharp objects which could pose a danger to residents are in locked storage, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not ensure that staff received eights hour dementia care training and four hours of training specific to postural supports, restricted health condition, and hospice care, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

87608(a)(3) Postural Supports: (a) Postural supports may be used under the following conditions...A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.This requirement is not met as evidenced by: Based on observation and record review, facility does not have written orders from a physician indicating the need for half bed rails in the rooms of R1, which is an immediate health, safety, or personal rights risk to persons in care.

Give PRN medication by physician order

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated…facility staff designated… (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement was not met as evidenced by: Based on observation, interview, and record review, the Administrator did not ensure one medication Lorazepam was administered correctly to resident (R1), which poses an immediate health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This regulation is not met as evidenced by: Based on observations, LPA observed prescription medications unlocked and accessible on the desk in the lobby area and no staff present. In addition, LPA observed the med-cart keys on the side of the med-cart accessible.

Maintain and operate facility under definitive plan

87208 Plan of Operation (a)The licensee shall have and maintain....The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so ...This requirement is not met as evidenced by Based on record review, the facility did not follow their plan of operation. The facility's program description states “Residents determined to have their physician diagnosis of mental disorder, unrelated to dementia shall not be accepted or retained. R1s primary diagnosis

Prohibit false or misleading facility statements

87207 False Claims No licensee, officer or employee of a licensee shall make…any false or misleading statement regarding the facility…This requirement is not met as evidenced by: Based on interview, S2 stated he/she checked R1 at 4:00am and later admitted that he/she lied. S1 was interviewed & stated CPR was administered prior to 911 call, however, S1 stated to SMCSO deputies he/she did not perform CPR. Administrator denied knowledge and witnessing that staff ties the door shut. On 5/14/25 ADM 2 was interviewed and admitted he has remote

Freedom to leave and not be locked in

87468.1(a)(6) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To leave or depart the facility at any time...This requirement is not met as evidenced by: Based on interviews and observations, the Licensee did not ensure that R2 and R3 had the right to leave their room at night by locking them in their rooms by tying the door knob to the hand rail, which is an immediate health, safety and personal rights risk to persons in care.

Conformance with applicable laws and regulations

87405(d)(2) Administrator - Qualifications and Duties... The administrator shall have the qualifications..(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requrement is not met as evidenced by: Based on interview, ADM denied having knowledge that staff are locking resident door. for over 12 hours and denied seeing the tie before. ADM stated that he/she did not know if S2 was interviewed and did not speak to S2 about the incident. S2 was written up/cited by law enforcement. ADM did not know what S2

Hold reappraisal meeting on changes

87463(i) Reappraisals: When there is significant change in condition... Definitions, or once every 12 months.., the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative...This requirement is not met as evidenced by: Based on document review, R2 had a reappraisal mentioning wandering, but it was not discussed with resident's responsible party, which is an immediate health, safety and personal rights risk to persons in care.

Care and supervision as defined by statute and rules

87464 Basic Services: (f)(1): Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code.This requirement is not met as evidenced by: Based on interviews, the facility failed to provide care and supervision by not checking in on R1, which is an immediate health, safety, or personal rights risk to persons in care.

Call 9-1-1 for imminent health threats

87465(g) Incidental Medical and Dental Care: (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including..This requirement is not met as evidenced by: Based on interviews, the licensee did not immediately telephone 911 when it was determined that R1 was not breathing, which is an immediate health, safety, or personal rights risk to persons in care.

Based on record review and interview of the Administrator, staff providing night supervision are familiar with the facility's planned emergency procedures, however no documentation of said training was available for review by the LPA, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review and interview with Administrator, the facility has conducted quarterly emergency drill trainings but does not have documentation of them, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the facility's LIC 610E(Emergency and Disaster Plan) was last updated on 12/9/2022, which poses/posed a potential health, safety or personal rights risk to persons in care.

Health screening and fitness requirements

Based on record review and interview of Administrator, Zach Pilkerton, S1's TB results/Health Screening Report were not present at the facility and could not be reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Keep bathing and hygiene facilities in operating condition

Based on observation, a faucet in residents room did not supply hot water, which poses/posed a potential health, safety or personal rights risk to persons in care.