Violations Filed Against Lakewood Assisted Living
The Peshtigo Times has learned that three separate complaint investigations by the Wisconsin Department of Health Services Division of Quality Assurance (DQA) resulted in Notices of Violation being filed against Lakewood Assisted Living, LLC, 17185 Flynn Lane, Lakewood. The 20-bed community based assisted living facility (CBRF) was ordered not to admit new or additional residents, submit plans of correction, pay over $20,000 in forfeitures, and fulfill several other special orders.
All of the DQA concerns have been taken care of, Kathy Ambrosius of Green Bay, one of the owners, stated on Wednesday morning, April 24.
She said she and other owners were shocked when the inspection and deficiency reports came out. We knew as owners we had to take control, and we did so immediately, she said, adding they now have corrected everything that was necessary and have submitted all reports to the state. As soon as the state has their scheduled visit we will again be able to accept new residents, she said.
Residents already in the facility continue to live there and Ambrosius expects new residents will be admitted as soon as the state inspection and recertification are complete.
We no longer have New Care managing it. Former Administrator Rebecca Marks has been replaced. We have hired a professional consultant and a new manager and are hiring all licensed employees.
Ambrosius explained the Lakewood CBRF owners had hired New Care to manage and run their facility because New Care has its own facility in Crivitz, and we thought they knew all the regulations, rules and proper care for the residents. New Care hired Marks as administrator.
The first Notice of Violation that led to the changes at the Lakewood facility was dated March 15, 2013, and identified 16 separate deficiencies. Addressed to Marks, who was then administrator, it indicates that on January 14, 2013 (with information gathered through February 11, 2013) a complaint investigation and verification visit was conducted by DQA to determine compliance with state statutes related to the administration and operation of the facility. Based on that investigation and the 16 deficiencies identified, the CBRF was ordered to pay fines/forfeitures totaling $19,850.
A second Notice of Violation and Order was sent to Lakewood on April 2, recounting a subsequent investigation of two additional complaints that resulted in five additional deficiencies identified on March 13. The order to not admit new or additional residents was extended and the facility was ordered to pay additional forfeitures of $5,480.
Two of the identified deficiencies cited failures to thoroughly investigate complaints from residents and staff members about the misconduct of a staff member.
According to the report, these complaints were investigated very sparsely, included no written statements, and failed to address all allegations presented.
A separate deficiency included failure to send a written report to the state following an incident when law enforcement had to be called to the facility. The investigation showed that 911 had to be called because a visitor was causing a disturbance. According to the report, when asked about failure to notify the department, the Administrator responded, I have to notify you? Okay, thats fine. I didnt know that.
Another deficiency indicated that the facility had failed twice to send written reports to the state reporting an incident or accident resulting in serious injury requiring hospital admission or emergency room treatment of a resident. In one of those incidents, a resident had fallen and received an injured foot/ankle. Emergency care was sought for the patient, but the facility failed to notify the department as required.
Multiple violations were noted involving resident care and services, health, safety and resident rights, all of which led the department to conclude that the license did not ensure qualified administration by supervising the daily operation of the facility.
These violations included inadequacies in staff training, failing to ensure continuing education of the staff, failure to make sure over half of the residents received their medications at the intervals prescribed by their physicians, failure to develop comprehensive individual service plans for at least five residents, failure to revise care plans when there was a change in condition, and failure to provide appropriate staff levels to meet the needs of the residents.
Along these same lines, other violations included the administration of medication without the delegation of a registered nurse or licensed practical nurse.
A particularly vivid violation of the failure to provide resident supervision noted that one resident was allowed to wander through another residents blood, which coated his feet, exposing him to possible blood borne pathogens.
In this same category were violations of failure to ensure the residents were provided with appropriate leisure time activities and failure to post a monthly schedule of community activities.
Lastly, a violation noted that the administration did not ensure that staff followed an infection control program.
In regard to the violations related to the facilitys administration, the outgoing Administrator explained that she took the position of Administrator in October of 2012, but was now leaving because the licensee decided he/she wanted a licensed nursing home administrator in the position and that she was not licensed.
Several staff members reportedly told investigators they were never trained on certain procedures. One even quit working at the facility because she was asked to perform procedures she felt should only be done by a nurse.
Another violation indicated that one specific caregiver made several documented medication errors (four in 40 days), but Administration failed to ensure the caregiver was competent to do so, nor was she retrained or counseled regarding it.
Other violations were directly related to Administrations failure to provide adequate staff on a 24-hour basis, which the reports indicated resulted in more resident falls, attempted elopements, and in some instances, residents waiting an entire week to receive a shower.
As a result of these violations, Lakewood was ordered not to admit any new or additional residents until the current violations are corrected and the facility is in compliance with the state. The facility was also directed to submit a plan of correction.
Special orders included that every resident and their families be notified of the violations, that a documented training and consultation plan be established, that administration immediately provide staff in sufficient numbers on a 24 hour basis, that all medications and medical devises be administered by a registered nurse or licensed practical nurse, and that the facility immediately provide a daily activity program to meet the interests and capabilities of the residents.
Lastly, based upon the 16 noted deficiencies, Lakewood Assisted Living was ordered to pay fines/forfeitures totaling $19,850.
A second Notice of Violation and Order was sent to Lakewood on April 2, 2013, recounting the investigation of two additional complaints resulting in five additional deficiencies cited on March 13, 2013. The order to not admit new or additional residents was extended and the facility was ordered to pay additional forfeitures of $5,480.
The first deficiency in that report noted the facilitys failure to report to the state when a residents whereabouts were unknown. The resident was later found to be safe - a friend had picked him up and they had left without informing anyone. The report states, however, that when staff discovered that the resident had left the facility they did not notify the administrator for almost two hours, and in turn, the administrator did not ever report the matter to the state.
A second deficiency noted that the facility did not ensure that a new cook was trained regarding safe food handling and exposure to blood, body fluids or other moist body substances, and had no formal dietary training.
Deficiency three revealed that a resident was left in bed on at least two occasions for approximately 17 consecutive hours, without toileting, food or drink. When the resident was finally taken care of, the bed was soaked and soiled with human waste. In addition, proper medication was also not offered or administered to the resident. That medication included treatment for bed sores.
Another deficiency dealt with the facilitys failure to provide or arrange services adequate to meet the needs of a resident for whom personal care services had been ordered to increase independence, for example staff-assisted physical therapy to meet minimum walking requirements.
At the time of the violations, Lakewood Assisted Living was being operated under the umbrella of NewCare Convalescent Center of Crivitz. The Peshtigo Times learned that this relationship had since been severed by owners of the Lakewood building, and this was confirmed by Ambrosius.
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