Lakeshore Rehabilitation Center LLC

Based on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers, failed to ensure food stored in the refrigerators and dry storage were labeled, dated and discarded properly. This deficient practice had the potential to affect all 48 residents, staff and visitors who received food from facility kitchen. Findings include: Freezer During the initial kitchen tour on 3/24/25 at 12:50 p.m., a walk-in commercial freezer had a cooling fan mounted to the top of the unit which had visible ice built up on numerous places along the unit. The ceiling of freezer had ice built up, thick in some areas and in frozen droplet forms in other areas, that went from the back wall of the freezer towards the front of the freezer cover two-thirds of the ceiling on the left side. The back wall of the freezer had ice build-up with the thickest of the ice towards the bottom with a mound of ice on the floor. [NAME] substance, approximately 5-inch…

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 document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R35) reviewed for self-administration of medications. Findings include: R35's admission Minimum Data Set (MDS) assessment dated [DATE], identified R35 had intact cognition and required assistance with all activities of daily living (ADL)'s. R35's diagnoses included atrial fibrillation, heart failure, hypertension, renal failure, diabetes mellitus, thyroid disorder and arthritis. MDS indicated R35 required substantial/maximal assistance with personal hygiene. R3's physician orders included order for Ipratropium-Albuterol inhalation solution 0.5-2.5% (3) mg (milligram)/3 ml (milliliter) - inhale one vial orally three times a day related to respiratory syncytial virus as the cause of diseases classified elsewhere. During interview and observation on 3/24/25 at 1:56 p.m., R35 was sitting in a wheelchair in her room. Nebulizer mask 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide assistance with facial hair removal for 1 of 1 resident (R35) reviewed for activities of daily living (ADL')s . Findings include: R35's admission Minimum Data Set (MDS) assessment dated [DATE], identified R35 had intact cognition and required assistance with activities of daily living (ADL)'s. R35's diagnoses included diabetes mellitus, and arthritis. MDS indicated R35 required substantial/maximal assistance with personal hygiene. R35's care plan lacked evidence of resident's shaving preferences. During observation and interview on 3/24/25 at 1:46 p.m., R35 had white facial hair on chin approximately 1 inch long. R35 stated staff has assisted before and would like to be shaved. During observation on 3/25/25 at 10:47 a.m., R35 continued to have facial hair on chin. During observation on 3/26/25 at 7:12 a.m., R35 continued to have facial hair on chin. During observation on 3/27/25 at 9:22 a.m., R35 continued to have facial hair 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 document review, the facility failed to monitor orthostatic blood pressures for 3 of 3 residents (R7, R8, and R32) and failed to ensure residents were routinely assessed for side effects who received physician ordered antipsychotic medications for 1 of 5 residents (R8), reviewed for unnecessary medications. Findings include: R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R7 had intact cognition and required assistance with all activities of daily living (ADL)'s. R7's diagnoses included orthostatic hypotension, depression, bipolar disorder, secondary Parkinsonism, mild cognitive impairment of uncertain or unknown etiology, and insomnia. R7's physician orders included Aripiprazole (antipsychotic) 10 milligram (mg) by mouth in the morning for bipolar disorder and Olanzapine (antipsychotic) 5 mg by mouth at bedtime for bipolar disorder. R7's medical record lacked evidence orthostatic blood pressures had not been obtained three out of six months for R7…

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 document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers using the main production kitchen. This had potential to affect all residents who could potentially consume the items. Findings include: On 5/28/24 at 9:57 a.m., an initial kitchen tour was completed. A single [NAME] walk-in commercial freezer was in use, opened and inspected. Inside, the unit had a cooling fan mounted to the top of the unit which had visible ice built up on numerous places along the unit. The ceiling of freezer had ice built up, thick in some areas and in frozen droplet forms in other areas, that went from the back wall of the freezer towards the front of the freezer cover two-thirds of the ceiling on the left side. The back wall of the freezer had ice build-up with the thickest of the ice towards the bottom. The floor of the freezer and the metallic shelving used also…

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 document review, the facility failed to ensure residents were assessed for appropriateness to be assisted by paid feeding assistants (PFA)'s at meals including residents with or without difficulty swallowing and/or with complicated feeding problems requiring a mechanically altered diet and/or special precautions for 6 of 6 residents (R4, R5, R6, R10, R16, and R30) reviewed. The facility also failed to ensure the PFA's were supervised at all times by a nurse while performing feeding assistance. Findings include: R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R4 had moderate cognitive impairment, was dependent on staff for Activities of Daily Living (ADL) and supervision or touching assistance for meals. R4's face sheet, printed 5/30/24, indicated R4 moved in on 1/12/10. Diagnoses included dementia with other behavioral disturbance, expressive language disorder, dsyarthria (speech disorder caused by weak muscles) following cerebral infarction…

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 interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 4 of 5 residents (R3, R2, R8, R24) reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should have shared clinical decision-making between the resident and healthcare provider to determine if PCV20 was appropriate. R3's quarterly Minimum Data Set (MDS), dated [DATE], identified R3 had moderate cognitive impairment, and several medical conditions including heart…

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 document review, the facility failed to ensure dignified, personal space was maintained for 1 of 1 resident (R8) who had staff enter their room without knocking or waiting for a response. In addition, the facility failed to ensure a dignified, homelike dining experience was provided for 1 of 1 resident (R29) observed to wait for an extended period of time for their meal despite tablemate's being served. Findings include: ROOM KNOCK: R8's annual Minimum Data Set (MDS) assessment, dated 2/29/24, identified R8 had moderate cognitive impairment and it was very important for her to be able to use the phone in private. On 5/28/24 at 11:01 a.m., R8 was seated in her personal room with the doorway closed to the unit' hallway. R8 was being interviewed by the surveyor when suddenly, without any audible knock or verbal warning, the doorway from the hallway opened and nursing assistant (NA)-A poked their head inside. NA-A turned and looked at the surveyor before turning back to R8 and voicing aloud, I'm just checking on you. NA-A then turned to the surveyor…

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 interview and document review, the facility failed to comprehensive assess and, if needed, develop interventions to ensure an appropriate, proactive bowel management program was implemented to promote comfort for 1 of 1 resident (R31) reviewed who complained about constipation. Findings include: R31's admission Minimum Data Set (MDS), dated [DATE], identified R31 had intact cognition and was continent of bowel. Further, the MDS outlined a question labeled, H0600, which asked if constipation was present. This was responded, No. R31's Retiring MHM (Monarch Healthcare Management) Admission/Initial Data Collection - V5, dated 4/5/24, identified R31 admitted to the care center from home and was on hospice care. The evaluation outlined R31 had not evident memory problem along with a section labeled, Current Bowel and Bladder Function, which asked four questions about continence. This identified R31 was occasionally incontinent of bowel, however, lacked any further questions or evidence to demonstrate R31's…

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 document review, the facility failed to mark/date opened containers of food stored in one kitchen refrigerators, a refrigerated sandwich prep table, and one freezer; and failed to ensure expired/damaged food were identified and removed. This had the potential to affect all 40 residents who were served food and beverages from the facility kitchen. Findings include: During interview and observation of kitchen on 6/6/23, at 11:50 a.m. with culinary director (CD)-D, observed food items in the refrigerated sandwich prep table, walk-in refrigerator, beverage service station refrigerator, and beverage service station freezer, that were not dated or marked and/or were expired/damaged. CD-D indicated all kitchen staff were responsible for checking food for opened dates and expiration dates, removing all expired/damaged foods when noted or per facility policy. CD-D indicated if any food or drink is not dated when opened, it should be removed immediately. CD-D indicated all left-over…

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 document review, the facility failed to assess the resident and determine safety for self-administration of medications (SAM) for 1 of 1 resident (R14) who was observed to have medications at bedside. Findings include: R14's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, required one-person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene, and indicated diagnoses including gastro-esophageal reflux disease (digestive disease), osteoarthritis, chronic kidney disease, coronary artery disease, heart failure, and hypertension (high blood pressure). R14's care plan dated [DATE], indicated risk for discomfort and interventions included: monitor for verbal and nonverbal indicators of discomfort, provide non medicinal forms of pain relief such as positioning, rest, massage, encourage resident to verbalize discomfort, document on pain, keep medical doctor informed. During an observation and 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 interview and document review the facility failed to complete a level II preadmission screening and resident review (PASARR) for 2 of 2 residents (R3, R5), reviewed with new mental illness diagnoses. Findings include: R3's face sheet, printed on 6/6/23, indicated R3's original admission date was 5/10/19, diagnosis at time included anxiety disorder. Further review of the diagnosis listed on face sheet, indicated R3 was diagnosed with a mood disorder on 6/16/21 and psychosis (a mental disorder causing disconnection from reality), not due to a substance or known physiological condition, on 3/17/22. R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had intact cognition and received antidepressant medication. R3's current physician orders, printed 6/6/23, included: monitoring for adverse side effects due to psychotropic medication use (medications altering mood/mental state), quetiapine fumarate (Seroquel, an antipsychotic (mood/mental state altering) medication); 125 mg twice daily…

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.