Lakeview Rehabilitation And Nursing LLC

Based on the interview and record review, the facility failed to prevent verbal abuse by a staff member who was fairly new to the facility position, and who had already received further education due to communication concerns while working with residents, but the staff member then verbally abused 1 (#3) resident of 5 sampled residents. This reflected the facility's abuse prevention program was not effective to prevent abuse for this resident. Findings include:Review of facility reported incident investigation showed on 4/23/26, [Resident #3] reported to [staff member C] that an incident occurred the previous evening on [4/22/26] at approximately 8:30 p.m. [Resident #3] stated that while receiving assistance with bedtime care, Certified Nursing Assistant (CNA) [NF4] spoke to her using what she described as 'gruff' language. The resident did not wish to have NF4 provide care to her any longer. The investigation showed a witness confirmed resident #3's allegation, and NF4 was terminated for abuse.During an interview on 5/6/26 at 11:37 a.m., staff member C stated resident #3 told her…

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 interview and record review the facility failed to document the required information for a resident discharge from the facility for 1 (#2) of 5 sampled residents. Findings include:During an interview on 5/7/26 at 9:08 a.m., staff member B stated the discharge for resident #2 was planned. Staff member B stated she was transferred to another facility by her family, although the documentation (in the EHR) does not show it. Staff member B stated the documentation expectation for a discharge would include a discharge planning assessment with the required discharge information, and on discharge, a discharge summary documented in the nurse's progress notes.Review of resident #2's EHR census tab showed she was discharged from the facility on 2/18/26.Review of resident #2's Nurse Progress Notes for February 2026 showed, Resident left at this time via [local transport company]. [Family member] was here to pack up her personal belongings. Medications sent with her. No other documentation was completed or found in the medical record to show the discharge was planned, where 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 interview and record review the facility failed to provide regular bathing to 1 (#2) of 5 sampled residents. Findings include:During an interview on 5/6/26 at 2:06 p.m., staff member E stated the residents were bathed at least once a week, with several scheduled twice a week. Staff member E stated they filled out forms for any resident refusals after several attempts, and the nurse on duty had to sign off.During an interview on 5/7/26 at 8:27 a.m., staff member B stated she might have had the old shower sheets (documents) for January and February (2026) for resident #2, but the timeframe was when the facility was implementing new forms to document their bathing process.During an interview on 5/7/26 at 8:37 a.m., staff member B stated she looked through forms and could not find any documentation showing resident #2 had showers from 1/10/26 until 2/2/26, per the EHR documentation.Review of resident #2's bathing documentation from January through February 2026 showed resident #2 did not receive bathing from 1/11/26 until 2/2/26; for 22 days.

Based on observation, interview, and record review, the facility failed to follow a planned and approved menu to ensure residents received the expected meals and nutrition. This deficient practice effected residents who ate meals prepared by the facility. Findings include:During an observation and interview, on 12/1/25 at 2:43 p.m., a package of sliced ham was observed in a black bin filled with water, on the three-compartment kitchen sink. Staff member F stated she had thawed out the ham because she did not have what she needed to make breakfast on the menu. Staff member B stated the facility would do substitutions verbally notifying the dietician but did not document the substitutions in any way. Staff member B did not know what the notification to the residents was, if any, of the menu changes when they happened. Staff member B stated the dietician was currently on vacation and the dietary manager was out.Review of the facility menu on 12/1/25, showed breakfast was to be a French toast bake, bacon, fresh fruit, and juice.During an observation on 12/3/25 at 8:41 a.m., residents…

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 food was served with an appetizing appearance and a palatable taste for 3 (#s 16, 18, and 19); and failed to serve altered food diets in an appealing manner for 1 (#28) of 14 sampled residents. This failure affected the residents' satisfaction and enjoyment of their food. Findings include:Review of the facility's lunch menu for 12/2/25, showed the facility served a honey glazed pork chop, baked potato, cauliflower, baked roll, and fruit cobbler.1. During an observation and interview on 12/2/25 at 12:30 p.m., resident #28 was sitting at her table in the dining room. She was eating lunch from a three-way sectioned plate that had a watery textured pureed meal. The plate contained three different watery purees in each separate section of the plate. All pureed items on the plate appeared to be white/beige in color. It was not obvious which section of the plate contained which food item. The resident asked the surveyor for sugar for her…

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 food was stored and distributed to residents in their rooms in a sanitary manner to protect food from cross contamination, food borne illnesses, and improper infection control practices. This practice had the potential to affect all residents receiving food delivered to their room. The facility failed to store, prepare, and serve food under sanitary conditions. This practice effected all resident who ate food prepared by the facility kitchen. Findings include: 1.During an observation on 12/2/25 at 12:58 p.m., staff member K was preparing to distribute the lunch service meal trays to residents in their rooms. The meal trays were loaded on a large, wheeled cart, that was not enclosed. There were 11 uncovered maroon colored bowls that contained a dessert. The beverage glasses on the cart were also uncovered. During an interview on 12/2/25 at 12:58 p.m., staff member K stated she was not aware if the drinks or the bowls with the dessert needed to be covered. During an interview on 12/2/25 at 1:00 p.m.,…

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 a resident's wheelchair was clean and well-maintained, and the soiled wheelchair bothered the resident, for 1 (#22) of 14 sampled residents. Findings include:During an observation on 12/1/25 at 3:15 p.m., resident #22 was laying in his bed. His wheelchair was next to the bed. The wheelchair had a large amount of piled up, brown and black dried and slivered debris as well as a sticky appearing debris on the frame of the wheelchair by the locks, on the arm rests, as well as the peddles. During an observation and interview on 12/2/25 at 9:19 a.m., resident #22's wheelchair had a large amount of piled up, brown and black dried and slivered debris as well as a sticky appearing debris on the frame of the wheelchair by the locks, on the arm rests, as well as the peddles. The resident stated he could not remember the last time his wheelchair was cleaned. He stated he preferred it to be clean, and it bothered him to have so much food debris…

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 comprehensive, person-centered care plans were developed and implemented for a resident with a left hand contracture and who had a diagnosis of Post Traumatic Stress Disorder for 1 (#25), and a resident who required physical therapy for 1 (#31), and the facility failed to care plan the risks and interventions for a resident's weight loss and swallowing risks for 1 (#28) of 14 sampled residents. The deficient practice increased the risk of decline in range of motion, re-traumatization, physical function and weight loss. Findings include:1. During an interview on 12/2/25 at 9:02 a.m., resident #25 stated she had not been seen by a provider for treatment of her post-traumatic stress disorder. Resident #25 became tearful when asked about the history of trauma and endorsed a history of traumatic events. During an observation on 12/2/25 at 9:22 a.m., resident #25 was observed with her left hand contracted. Review of resident #25's admission MDS with an ARD of 10/28/25, showed under section I6100 (diagnosis),…

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 interview and record review, the facility failed to provide regular showers for 2 (#s 21 and 31) of 14 sampled residents. Findings include:1. During an interview on 12/1/25 at 2:28 p.m., NF1 stated there were weeks where resident #21 did not receive a shower. NF1 further stated resident #21 was supposed to have had a shower two times per week.Review of resident #21's Baseline Care Plan, dated 3/9/25, showed resident #21 preferred to have showers two times per week.Review of resident #21's Comprehensive Care Plan, last reviewed on 9/29/25 showed, .Focus: [Resident Name] has an ADL self-care performance deficit r/t hx CVA, Date initiated: 5/19/25. Goal: [Resident Name] will maintain current level of function in ADLs through the review date. Interventions: BATHING/SHOWERING: [resident name] requires maximum assist by 1 staff with bathing and showering one time week and as necessary - per her preference. [sic]Review of resident #21's Tasks List for showers for the last 30 days showed resident #21 had a shower once per week.Review of the weekly shower schedule, updated 11/6/25,…

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 observation, interview, and record review, the facility failed to identify a resident's contracture, risk factors of the contracture, and failed to assess and implement preventative measures to prevent further decline in the contracture, for 1 (#25) of 14 sampled residents. This deficient practice increased the risk of the resident's contracture worsening. Findings include:During an observation on 12/2/25 at 9:22 a.m., resident #25 was observed with her left hand contracted.During an interview on 12/4/25 at 7:18 a.m., staff member M stated she thought there was something on the TAR about it (left hand contracture) but could not find anything in the orders regarding resident #25's left hand contracture. Staff member M did note the left-hand contracture was listed on the CNA task sheet.During an interview on 12/4/25 at 7:19 a.m., staff member L stated she was unaware of resident #25's left hand contracture.During an interview on 12/4/25 at 7:25 a.m., staff member B stated she was informed of resident #25's left hand contracture on the day prior. Staff member B stated there…

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 identify the risks and put interventions in place to prevent a significant weight loss of 12 percent over 41 days, for 1 (#28) of 14 sampled residents. Findings include:During an observation on 12/3/25 at 8:47 a.m., resident #28 was in the dining room for breakfast, and her food was pureed in separate containers. Resident #28 had eaten some food and was trying to get a condiment container of brown sugar open to eat, but did not know what it was.During an interview on 12/3/25 at 10:52 a.m., staff member N stated he went to nutrition at-risk meetings, and they would determine as a team what interventions were needed for a resident. Staff member N stated that nursing would monitor residents' weights.During an interview and observation on 12/3/25 at 11:51 a.m., staff member L looked up resident #28's chart and stated resident #28 had a choking incident on 11/9/25 and had been downgraded to a pureed diet that the resident hated. Staff member L…

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 identify a resident's past history of trauma and identify triggers that may cause re-traumatization for 1 (#25) of 14 sampled residents. This deficient practice increased the risk for the resident to experience trauma that could have been prevented. Findings include:During an observation and interview on 12/2/25 at 9:02 a.m., resident #25 stated she had not been seen by a provider for treatment of her post-traumatic stress disorder. Resident #25 became tearful when asked about the history of her trauma and she endorsed a history of traumatic events.Review of resident #25's admission MDS with an ARD of 10/28/25, showed under section I (active diagnoses), Psychiatric/Mood disorder, I6100: resident #25 had a diagnosis of post-traumatic stress disorder.During an interview on 12/3/25 at 2:16 p.m., staff member A stated trauma informed care assessments were not being completed.A request was made for resident #25's trauma assessment on 12/3/25 at 2:18 p.m.Review of resident #25's Resident Trauma Interview, dated…

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 record review, the facility failed to ensure specialized rehabilitation services were delivered as ordered by the physician and failed to further assess and monitor for the need for continued specialized therapy services for 1 (#31) of 14 sampled residents. This deficient practice limited the opportunity for the resident to achieve her highest level of physical function. Findings include:During an interview on 12/1/25 at 3:05 p.m., resident #31 reported concern about the lack of physical therapy she had received. Resident #31 stated she would have to go ask them (the staff) about when or how often she was to be seen by therapy.Review of resident #31's, [Facility Name] Healthcare Discharge Orders, dated 7/28/25, reflected resident #31 was to be seen by physical therapy twice weekly.Review of Physician's Order, dated 8/5/25, showed, .Description: PT order per [Physician Name] at [Facility Name] Ortho: PT eval and treat for muscle strengthening and active assisted ROM 2-3x/week 8-10 weeks.…

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.