Lakeview Terrace Rehab And Health Care Center

Based on record review and interview, the facility failed to ensure the arbitration agreement included the required elements for 3 of 3 residents reviewed for arbitration (Residents #11, #36, and #35). Findings include:Review of Skilled Nursing Facility admission and Financial Agreement for Resident #11 entered into on 7/8/2025 between the facility and Resident #11 showed it contained a section titled 44. Dispute Resolution, which did not contain the information specifying that signing the dispute resolution was not a requirement of admission or continuing care; the resident or representative could rescind the dispute resolution within 30 days of signing; the resident was not prohibited from communicating with other entities or agencies; the arbitration would be held in a location convenient to both parties; and the resident or representative understood the dispute resolution agreement.Review of Skilled Nursing Facility admission and Financial Agreement for Resident #35 entered into on 12/11/2025 between the facility and Resident #35 showed it contained a section titled 44. Dispute…

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 interview, the facility failed to ensure the arbitration agreement provided for the selection of a venue convenient to both parties for 3 of 3 residents reviewed for arbitration (Residents #11, #36, and #35).Findings include:Review of Skilled Nursing Facility admission and Financial Agreement for Resident #11 entered into on 7/8/2025 between the facility and Resident #11 showed it contained a section titled 44. Dispute Resolution, which failed to specify that the arbitration would be held in a location convenient to both parties.Review of Skilled Nursing Facility admission and Financial Agreement for Resident #35 entered into on 12/11/2025 between the facility and Resident #35 showed it contained a section titled 44. Dispute Resolution, which failed to specify that the arbitration would be held in a location convenient to both parties.Review of Skilled Nursing Facility admission and Financial Agreement for Resident #36 entered into on 9/22/2025 between the facility and Resident #35 showed it contained a section titled 44. Dispute Resolution, which failed…

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 and interview, the facility failed to ensure accurate nurse staffing data was posted on a daily basis.Findings include:During an observation on 9/29/2025 at approximately 9:50 AM, the nurse staffing report posted on the Skilled Nursing Unit documented the resident census as 39 (Photographic evidence obtained).During an interview on 9/29/2025 at 9:51 AM, Staff C, Licensed Practical Nurse (LPN), stated that the posted staffing was not correct and the census should have been documented as 29 and it should be corrected.During an interview on 9/30/2025 at 1:43 PM, the Director of Nursing (DON) stated that the expectation was the daily staffing sheet was to be completed by the 11-7 shift [11:00 PM - 7:00 AM] and that the resident census was based on the midnight census. It was not possible that the midnight census on 9/29/2025 was 39, as was documented on the staffing report.

Based on observation, interview, and record review, the facility failed to ensure food was properly stored in 2 of 2 service kitchens (Rehabilitation Unit kitchen and Skilled Nursing Unit kitchen) and failed to ensure food was prepared in a sanitary manner. Findings include:During an observation on 9/29/2025 at 9:55 AM, there were four frozen individually wrapped packages of pancakes in a clear plastic packaging with no label inside of a plastic bin with no label or date inside of a freezer located in the skilled nursing facility kitchen.During an interview on 9/29/2025 at 9:55 AM, Staff F, Certified Dietary Manager (CDM), stated, We did not serve pancakes for breakfast today. We served waffles.During an observation on 9/29/2025 at 10:20 AM, there were one opened container of chocolate syrup, one opened container of mayonnaise, one opened container of hot sauce, and one opened sweet relish the Rehabilitation Unit refrigerator, which were not labeled with opened or discard by dates (Photographic evidence obtained).During an interview on 9/29/2025 at 10:20 AM, Staff F, CDM, stated,…

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 interview, the facility failed to coordinate assessments for the residents with newly evident or possible serious mental disorder for 1 of 3 residents reviewed for mood and behavior (Resident #6).Findings include:Review of Resident #6's admission record showed the resident was admitted on [DATE] with diagnoses that included major depressive disorder (onset date of 3/28/2023), adjustment disorder with mixed anxiety and depressed mood (onset date of 1/4/2024), and primary insomnia (onset date of 4/20/2023).Review of Resident #6's Preadmission Screening and Resident Review (PASRR), completed on 12/16/2024, did not include major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, and primary insomnia as mental illness under Section I: PASRR Screen Decision-Making.Review of Resident #6's psychiatry subsequent note dated 9/10/2025 read, Chief Complaint: Depression, anxiety, dementia, insomnia, mood disorder, psychosis and Parkinsonism. Diagnostic Assessment 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 interview, the facility failed to ensure medical records were complete and accurate regarding medication administration and blood sugar monitoring for 1 of 5 residents reviewed for unnecessary medications (Resident #2).Findings include:Review of Resident #2's physician order dated 9/3/2025 read, Accu-check blood sugar monitoring, two times a day.Review of Resident #2's Medication Administration Record (MAR) for blood sugar monitoring two times a day (discontinued on 9/19/2025 at 2:07 PM) for September 2025 revealed the resident refused the blood sugar check on 9/6/2025 at 9:00 AM and 9:00 PM, 9/7/2025 at 9:00 AM, 9/8/2025 at 9:00 AM, 9/9/2025 at 9:00 AM and 9:00 PM, 9/10/2025 at 9:00 PM, 9/11/2025 at 9:00 PM, 9/12/2025 at 9:00 AM and 9:00 PM, 9/13/2025 at 9:00 AM and 9:00 PM, 9/14/2025 at 9:00 PM, 9/15/2025 at 9:00 AM and 9:00 PM, 9/16/2025 at 9:00 AM and 9:00 AM, 9/17/2025 at 9:00 AM and 9:00 PM, 9/18/2025 at 9:00 AM and 9:00 PM, and 9/19/2025 at 9:00 AM.Review of Resident #2's physician order dated 9/19/2025 read, Accu-check blood sugar monitoring, twice…

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, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration when required to prevent the possible spread of infection and communicable diseases.Findings include:During an observation on 10/1/2025 at 10:00 AM, Staff B, Licensed Practical Nurse (LPN), was preparing oral medications for Resident #25. Staff B touched a Ferrous Sulfate tablet with her ungloved hand. During administration, Resident #25 dropped a tablet from the medication cup into her lap. Staff B picked up the tablet with her ungloved hand and handed it to Resident #25 for oral administration.During an interview on 10/1/2025 at 10:08 AM, Staff B, LPN, stated that she usually attempted to just pour the pills out of the bulk bottle into the bottle lid and then into the cup because she knew she was not supposed to touch the medications. Staff B confirmed that she used her ungloved hand to pick up a tablet and hand it to Resident #25.During an interview on 10/2/2025 at approximately 9:00 AM, the Director of Nursing (DON) stated that 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.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration for 6 of 10 medication administration observations to prevent the possible spread of infection and communicable disease. Findings include: 1. During an observation on 7/10/2024 at 5:55 AM, Staff E, Licensed Practical Nurse (LPN), exited the nurses' station and went to the medication cart, removed keys from her pocket, unlocked the medication cart and prepared Resident #140's medications without performing hand hygiene. Staff E donned gloves without performing hand hygiene and locked the medication cart with her gloved hand. Staff E knocked on Resident #140's room door with her gloved hand, entered the resident's room, used the bed controls to adjust the height of the head of the bed with her gloved hands and administered Resident #140's oral medications. Staff E then pulled a syringe and alcohol swab out of her pocket with her gloved hand, cleaned Resident #140's arm with alcohol and administered medication to the resident. Staff E doffed…

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 interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 2 of 3 residents reviewed for respiratory services, Residents #3 and #23. Findings include: 1. Review of Resident #3's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified dementia, hypertensive heart and chronic kidney disease without heart failure, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery, and stage 3B chronic kidney disease. Review of Resident #3's physician order dated 2/24/2023 read, Oxygen at 2.5 LPM [liters per minute] via nasal cannula PRN [as needed] for O2 sats [oxygen saturation] below 90% as needed related to facial weakness following cerebral infraction. Review of Resident #3's Weights and Vitals Summary for O2 sats summary showed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure comprehensive person-centered care plans were developed for 3 of 12 residents reviewed, Residents #2, #3, #33. Findings include: Based on record review and interview, the facility failed to ensure comprehensive person-centered care plans were developed for 3 of 12 residents reviewed, Residents #2, #3, and #33. Findings include: 1. Review of Resident #33's admission record documented the resident was most recently admitted on [DATE] with diagnoses that included chronic atrial fibrillation, essential (primary) hypertension, arthritis, generalized anxiety disorder, muscle weakness (generalized), unsteadiness on feet, and major depressive disorder. Review of Resident #33's physician order dated 2/9/2024 read, Eliquis Oral Tablet 5 mg [milligram] (Apixaban), Give one tablet by mouth every 12 hours for A-fib. Review of Resident #33's care plan dated 5/16/2024 showed no focus or intervention related to anticoagulant therapy. During an interview on…

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, interview, and record review, the facility failed to ensure residents received oxygen as ordered by the physician for 1 of 3 residents reviewed for respiratory care, Resident #23. Findings include: Review of Resident #23's admission record showed the resident was most recently admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease (COPD), unspecified atrial fibrillation, cerebral infarction due to embolism of right middle cerebral artery, essential (primary) hypertension, cerebral aneurysm, other seizures, and anemia. Review of Resident #23's physician order dated 11/17/2023 read, Oxygen at 2 LPM [liters per minute] via nasal cannula continuously every shift. During an observation on 7/8/2024 at 9:38 AM, Resident #23 was resting in bed, being administered oxygen at 4 liters per minute via…

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, interview, and record review, the facility failed to ensure the dressing on a Peripherally Inserted Central Catheter (PICC) line was changed every 48 hours as per professional standards of care for 1 of 1 resident with a PICC Line, Resident #36. Findings include: During an observation on 3/15/2023 at 2:30 PM, Resident #36 had a PICC line on left upper arm with gauze under transparent dressing. The dressing was dated 3/10/23 (photographic evidence obtained). Review of the admission record for Resident #36 revealed the resident was admitted to the facility on [DATE] with diagnoses including fusion of spine, spinal stenosis of lumbar region, and lower back pain. Review of Resident #36's Medication Administration Record (MAR) revealed the PICC line dressing change was completed on 3/14/2023. Review of the physician orders for Resident #36 reads, Order Summary: Change PICC site dressing on admission, then once weekly and PRN [as needed] every day shift every 7 day(s) for PICC care. Order Date:…

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.