Lakeshore Post Acute And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for three (#3, #11 and #14) of four residents reviewed for baseline care plans out of 22 sample residents. Specifically, the facility failed to ensure pertinent medical information was included on Resident #3, Resident #11 and Resident #14's baseline care plans within 48 hours of admission. Findings include: I. Facility policy and procedure The Comprehensive Person-Centered Care Planning, revised January 2022, was received from the nursing home administrator (NHA) on 2/26/25 at 5:08 p.m. It read in pertinent part, The interdisciplinary team (IDT) will develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three (#10, #6, and #4) of three residents reviewed for activities programming out of 22 sample residents. Specifically, the facility failed to offer and provide personalized activity programs for Resident #10, #6 and #4. Findings include: I. Activity calendar The February 2025 activity calendar for the week of 2/23/25 through 2/28/25 revealed there were seven to eight activities scheduled per day. The activity calendar had mind-stimulating activities scheduled on four of seven days for the week (2/23/25, 2/24/25, 2/25/25 and 2/26/25) in the form of Bingo. There was only one activity scheduled for the week for non-social dementia residents in the form of Puppy Friday (2/28/25).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; and, -Beard restraints were worn in kitchen areas while serving food. Findings include: I. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. 36 Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds. B. Observations and staff interview On 10/25/23 at 9:55 a.m. the cook (CK) had prepared the pork that was from the oven and placed it in a large metal container. The CK poured a large bottle of barbeque into the pan of pork…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning resident care and dignity. Findings include: I. Facility policy and procedure The Resident Council policy, revised February 2021, was provided by the corporate nurse consultant (CN) on 10/25/23. It read in pertinent part, The purpose of the resident council is to provide a forum for discussion of concerns and suggestions for improvement. A resident council response form will be utilized to track issues and their resolutions. The facility department related to any issues will be responsible to address the item(s) of concern. II. Resident interview The resident council president, Resident #23, was interviewed on 10/26/23 at 10:19 a.m. She stated she did not know who was supposed to handle the grievances brought up in the council meeting. The council did not receive a resolution for grievances brought up in prior…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 14 of 60 resident rooms in six hallways. Specifically, the facility failed to ensure walls, baseboards and doors were properly maintained. Findings include: I. Initial observations Observations of the resident living environment were conducted on 10/24/23 at 1:24 p.m. revealed: Room #C-21: The resident's sink had a one inch ring of rust around the drain. The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. The vent on the ceiling had peeling and chipped sheetrock approximately two inches around the whole vent. The wood railing outside of C hall had chipped and splintering corners approximately three inches long and a half inch wide. The sheet rock was chipped and peeling with metal corners exposed. The nursing station had swinging doors that were removed. The area where the door hinges were located had chipped and damaged sheet rock approximately five inches long by four inch wide. The corner had chipped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure five (#13, #38, #3, #23 and #52) of eight residents were free from unnecessary psychotropic medications out of 32 sample residents. Specifically, the facility failed to: -Monitor targeted behaviors and individualized non-pharmacological approaches for psychotropic medications for Residents #13, #38 and #3; -Follow pharmacist recommendations for gradual dose reductions of psychoactive medications for Resident #3 and #23; -Ensure risks were reviewed for an antipsychotic medication prior to administration for Resident #3; and, -Ensure as-needed (PRN) orders for psychotropic/antipsychotic medication did not extend 14 days without documented clinical rationale from the physician or a physician evaluation of the resident for Residents #52 and #23. Findings include: I. Facility policy The Behavior Monitoring policy dated 3/10/23, was provided by the corporate nurse consultant (CN) on 10/25/23 at 3:36 p.m. It read in pertinent part: The purpose of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as COVID-19 for three of six units Specifically, the facility failed to ensure: -Staff performed hand hygiene between glove use; -Staff wore personal protective equipment (PPE) when entering COVID positive rooms; -Staff doffed (removed) gowns prior to exiting a COVID positive room; and, -A COVID positive resident did not occupy areas frequented by COVID negative residents. Findings include: I Professional reference According to the Centers for Disease Control (CDC) guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 6/3/2020, retrieved on 11/2/23 from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf. It read in pertinent part, -PPE must be donned correctly before entering the patient area. -PPE must remain in place and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNAs) consisted of annual training for dementia management for six of six CNAs reviewed. Specifically, the facility failed to ensure CNAs #3, #4, #5 #6, #1 and #2 received annual dementia management training. I. Training review Six nurse aides were reviewed for the annual required dementia management training. Training records revealed six of the six did not have the required annual training: CNA #3 was hired on 7/7/22. She had not had annual dementia management training. CNA #4 was hired on 1/21/21. She had not had annual dementia management training. CNA #5 was hired on 10/27/22. She had not had annual dementia management training. CNA #6 was hired on 8/31/21. She had not had annual dementia management training. CNA #1 was hired on 8/23/22. She had not had annual dementia management training. CNA #2 was hired on 1/12/22. She had not had annual dementia management training. II. Interview The director of nursing (DON) was interviewed 10/25/23 at 4:35 p.m.She said the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure two (#31 and #55) out of four residents reviewed for abuse were kept free from abuse out of 32 sample residents. Specifically, the facility failed to: -Prevent a resident-to-resident altercations between Resident #58 and #55; and. -Prevent a resident-to-resident altercation between Resident #58 and #31. Findings include: I. Facility policy and procedure The Abuse policy, dated 5/3/23, was provided by the director of nursing (DON) on 10/23/23 at 4:28 p.m., included in part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. II. Resident #58 A. Resident status Resident #58, age [AGE], was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of convenience, and the least restrictive alternatives were used for two (#52 and #11) of three residents reviewed for restraints out of 32 sample residents. Specifically, the facility failed to: -Obtain a physician's order for a lap buddy for Resident #52 and #11; -Obtain consent before the use of a lap buddy for Resident #52 and #11; and, -Evaluate the ongoing use of a lap buddy for Resident #52 and #11. Findings include: I. Facility policy and procedure The Restraint Free Environment policy, implemented 12/1/22, was provided by the director of nursing (DON) on 10/25/23 at 3:10 p.m. included: Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to report alleged violations of potential abuse administration in accordance with State law involving one resident (#54) of four residents reviewed for abuse out of 32 sample residents. Specifically, a certified nurse aide failed to report verbal abuse immediately that she witnessed to facility administration by a nurse towards Resident #54. She documented it on a concern form and failed to take further action. Findings include: I. Facility investigation Review of the incident report on 4/30/23 revealed a certified nurse aide (CNA) #10 reported on a concern form that a nurse was verbally abusive toward a resident. 4/29/23 Concern form: (CNA) reported to the RN that the resident did not want to take a shower and (the CNA) asked for help. (The RN) threw the blankets off of him and told him you are getting in the shower. She continued to tell him that he needed to lose weight because he looked pregnant, making fun of him for the way his pants and underwear looked stating that he looked like he was wearing maternity pants.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide services by qualified persons for one (#71) out of 32 sample residents. Specifically, the facility failed to ensure Residents #71 was assessed by a registered nurse (RN) following a fall. Findings include: I. Resident status Resident #71, age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included atrioventricular block, atrial fibrillation, chronic obstructive pulmonary disease (COPD), urinary tract infection and kidney failure. According to the 7/31/22 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident had no falls since admission. II. Record review The care plan, initiated 5/4/23 and revised 10/19/23, identified the resident was at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to provide hearing assistive devices to residents for one (#22) of three residents reviewed for hearing devices out of 32 sample residents. Specifically, the facility failed to ensure the availability and education with staff on the use of hearing aides as ordered for Resident #22. Findings include: I. Resident #22 A. Resident status Resident #22, age over 65, was admitted on [DATE] and readmitted [DATE]. According to the October 2023 computerized physicians orders (CPO), diagnoses included Alzheimer's disease, vertigo and bilateral (both ears) hearing loss. The 8/22/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. She had the identified behaviors of wandering during the assessment period. The assessment identified the use of hearing aides. B. Observations The resident was observed on 10/23/23 at 11:10 a.m. without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for one (#58) of three residents reviewed for accidents/hazards out of 32 sample residents. Specifically, the facility failed to ensure Resident #58 identified as a fall risk wore non-skid footwear while ambulating as identified in the care plan. Findings include: I. Resident #58 A. Resident status Resident #58, age [AGE], was admitted on [DATE]. According to the October 2023 computerized physicians orders (CPO), diagnoses included dementia, cognitive deficit and muscle weakness. The 7/28/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. The resident needed the assistance of one person for dressing. No falls were identified on the assessment. B.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#183) of three residents reviewed for supplemental oxygen use out of 32 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Resident #183. Findings include: I. Facility policy The Oxygen Administration Policy, revised 4/14/23, was provided on 10/25/23 at 1:55 p.m. by the nursing home administrator (NHA). It read in pertinent part, Oxygen is administered and stored to residents who need it, consistent with professional standards of practice, comprehensive person centered care plans, and the resident's goal and preferences. II. Resident #183 A. Resident status Resident #183, age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included chronic respiratory failure, venous insufficiency and psychophysiology insomnia. According to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents who were diagnosed with Alzheimer's/dementia received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for one (#58) out of four residents reviewed for mood and behavior out of 32 sample residents. Specifically, the facility failed to: -Develop a person centered individualized care plan with effective interventions for Resident #58; and, -Train staff on individualized person centered interventions for aggressive behaviors for Resident #58. Findings include: I. Resident #58 A. Resident status Resident #58, age [AGE], was admitted on [DATE]. According to the October 2023 computerized physicians orders (CPO), diagnoses included dementia, cognitive deficit and muscle weakness. The 7/28/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of one out of 15.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews, the facility failed to ensure a call light was within the reach of one (Resident #40) of one sampled resident who was reviewed for accommodation of needs. Findings included: A review of Resident #40's admission Record revealed the facility admitted the resident with diagnoses of anxiety, contracture of left hand, contracture of left ankle, contracture of left foot, bladder disorder, cerebral infarction, and hemiparesis following cerebral infarction. A review of a quarterly Minimum Data Set assessment, dated 05/25/2022, revealed the resident scored 13 on a Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The resident required extensive assistance of two or more people with bed mobility, transfers, locomotion, dressing, and toilet use. The MDS further indicated the resident had functional limitation in range of motion, with impairment to one upper extremity and one lower extremity. Per the MDS, the resident was frequently incontinent of bladder and always incontinent of bowel. A review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure notification of a facility-initiated transfer, including the reason for the transfer, was provided to the resident/representative for 1 (Resident #5) of 1 sampled resident reviewed for transfer notice requirements. Findings included: Review of a facility policy titled, Transfer and Discharge (including AMA-against medical advice), dated 10/01/2022 (sic), revealed, It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility except in limited situations when the health and safety of the individual or other residents are endangered. The policy also indicated, Provide transfer notice as soon as practicable to resident and representative. k. Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. A review of Resident #5's admission Record revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to ensure a resident/resident representative was provided with information regarding the facility's bed-hold and reserve bed payment policy upon transfer to a hospital for 1 (Resident #5) of 1 sampled resident reviewed for transfer requirements. Findings included: A review of the facility's Bed Hold Policy, revised September 2021, revealed, Upon request, Facility shall hold Resident's bed when Resident is away from Facility for medical leave or on therapeutic leave, as long as applicable bed-hold fee, if any, is paid. Except as provided below, the daily bed-hold fee is the current daily charge for the Resident's room and board. Medicaid will pay appliable bed-hold charges for up to 42 days of therapeutic leave only. If a Medicaid resident is on medical leave or exceeds 42 days of therapeutic leave in a single year, the facility may charge the Resident a bed-hold fee not to exceed the Medicaid daily rate minus $2.00. However, no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and facility policy review, the facility failed to maintain a medication error rate of less than 5%. During medication administration observations, there were three medication errors out of 34 opportunities, which resulted in an 8.82% medication error rate for 2 (Resident #3 and Resident #13) of four residents observed during medication administration. Findings included: Review of a facility policy titled, Medication Administration, dated 10/01/2022, revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 1. A review of an admission Record revealed the facility admitted Resident #13 on 03/19/2019 with diagnoses including chronic obstructive pulmonary disease (COPD) with acute exacerbation, acute respiratory failure with hypoxia, and schizophrenia. A review of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.