Lakeside Health & Rehab Center

Based on observations and interviews, the facility failed to clean a circulatory fan cover in the walk-in refrigerator and prevent condensation from forming and dripping onto stored food, which resulted in water standing on the floor of the walk-in refrigerator. This issue was identified for 1 of 3 refrigerators (walk-in) observed in the kitchen. The deficient practice had the potential to affect food served to some of the 103 residents residing in the facility. The findings included:On 12/8/25 at 9:48 AM, an observation of the walk-in refrigerator was conducted with the Dietary Manager. The circulatory fan cover contained a thick build-up of gray/brown debris that was crumbly to touch and covered the entire fan cover. Condensation droplets were observed on the bottom of the circulatory fan and drops of condensation had fallen onto a covered container of sliced tomatoes stored directly under the circulatory fan. Additionally, standing water, brown in color, was present on the floor beneath the fan.On 12/8/25 at 9:54 AM the Dietary Manager stated she was not aware of the debris 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 observations, record review, and interviews with resident and staff, the facility failed to maintain a clean shower room for 2 of 3 shower rooms observed. The facility also failed to maintain a wheelchair in good repair for 1 of 4 residents reviewed for mobility devices (Resident #99). The findings included: 1.a. An observation conducted on 12/10/25 at 10:14 AM of the 100-hall shower room with the Environmental Service Manager revealed a black/gray substance covering the tile floor of the resident shower stall. The black/gray substance covered the surface area in the middle of the shower stall near the shower drain and extended up the right side of the shower wall leading to the shower control knobs. The black/gray substance was also observed in the cracks of the shower tile lining the shower stall. b. An observation and interview conducted on 12/10/25 at 10:25 AM of the 300-hall shower room with the Environmental Service Manager revealed a black/gray substance lining the cracks of the shower stall 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 record reviews and staff interviews, the facility failed to accurately complete a comprehensive assessment in the area of diagnoses for 1 of 22 resident assessments reviewed (Resident #10). The findings included:Resident #10 was admitted to the facility on [DATE]. Resident #10's diagnoses included congestive heart failure, end stage renal disease, atrial fibrillation (an abnormal heart rhythm), and hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease. A review of Resident #10's physician's orders revealed the following orders dated 11/18 25: - Midodrine (a medication used to treat low blood pressure) 5 mg by mouth three times daily.- Metoprolol (a beta blocker medication that treats congestive heart failure and atrial fibrillation) 25 mg by mouth daily. A care plan was initiated 11/18/25 for cardiovascular risk due to diagnosis of congestive heart failure (CHF) and the use of oxygen. The stated goal was Resident #10 would not exhibit respiratory distress…

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, and staff interviews, the facility failed to store ammonium lactate lotion (prescription-strength lotion), antifungal powder, and betadine solution (topical antiseptic solution) in a locked cart. These items were found unsecured on a resident's bedside table. This occurred for 1 of 5 residents reviewed for medication storage (Resident #64). Additionally, the facility failed to date one opened bottle of Latanoprost after it was opened and failed to store one bottle of Latanoprost in accordance with manufacturer's storage guidelines for 1 of 5 medication carts (600 Hall). The findings included: 1. Resident #64 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and hidradenitis suppurativa (skin condition that causes chronic rashes and infections). Resident #64's quarterly Minimum Data Set, dated [DATE] coded Resident #64 with severe cognitive impairment. The MDS did not code the resident for ski problems or rashes. Resident #64's physician…

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, and interviews with resident and staff, the facility failed to ensure dependent residents could access the light switch located behind the bed for 1 of 1 resident reviewed for accommodation of needs (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's medical record revealed she had stayed in room [ROOM NUMBER] since 08/16/23. The quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #2 with a moderately impaired cognition. The MDS indicated walking between locations inside the room for more than 10 feet did not occur for Resident #2 during the assessment period. During an observation conducted on 09/23/24 at 3:44 PM, the switch cord for the light fixture on the wall behind Resident #2's bed was approximately 5 feet from the floor and 6-7 feet from the bed. The switch cord was approximately 4 inches in length. Resident #2 was unable to reach the switch cord from the bed if needed. An interview was conducted with…

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, observation and staff interviews the facility failed to follow a physician order to apply a splinting device for 1 of 2 residents (Resident #14) reviewed for range of motion. The findings included: Resident #14 was admitted to the facility on [DATE] with a diagnosis that included contracture to the left hand. Occupational Therapy (OT) Discharge summary dated [DATE] indicated recommendations that stated palm guard to left hand 8 hours to facilitate contracture management. On 09/25/2024 at 10:58 AM, an interview with the Director of Rehabilitation revealed on 11/2/2023 Occupational Therapy educated nursing how to don and doff the palm guard to the left hand of Resident #14. A physician order dated 04/04/2024 stated a palm guard should be applied to Resident #14's left hand every day for 8 hours as tolerated. A care plan dated 06/19/2024 revealed Resident #14 had limited physical mobility related to contracture, left-side hemiplegia, and history of stroke. The approaches included first shift…

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 reviews and staff interviews, the facility failed to check a finger-stick blood sugar (FSBS) for 1 of 6 residents reviewed for unnecessary medications (Resident #311). The findings included: Review of the hospital Discharge summary dated [DATE] revealed Resident #311 had an order for Metformin (anti-diabetic medication) 500 milligrams (mg) twice a day. There were no orders for finger-stick blood sugar (FSBS) checks. Resident #311 was admitted to the facility on [DATE] with multiple diagnoses which included surgical repair of right hip fracture, diabetes, and asthma. Documentation on the care plan initiated 2/21/2024 revealed Resident #311 had diabetes mellitus with interventions to assess, document, and report to physician signs and symptoms of hypoglycemia (low blood sugar) such as sweating, tremors, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, and staggered gait. A review of the facility admission orders dated 2/21/2024 revealed Resident #311 had…

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, staff interviews and record reviews, the facility failed to date a bottle of eye medication after it was opened and failed to discard 2 bottle of expired eye medications from the medication cart as specified by manufacturer's guidelines for 2 of 5 medication carts observed during medication storage checks (100 hall and 700 hall medication carts). The findings included: a. The manufacturer's package inserts for Latanoprost eye drops revealed an unopened bottle should be stored under refrigeration between the temperature of 36° to 46° Fahrenheit (F) and protected from light. Once it was opened, Latanoprost could be stored at room temperature up to 77° F for up to six weeks. A medication storage audit was conducted on 09/24/24 at 2:46 PM for the 100 hall medication cart in the presence of Nurse #2. One opened bottle of Latanoprost 0.005% eye drops without an opened date was found in the medication cart at room temperature and available for use. An interview was conducted with Nurse #2 on 09/24/24 at 2:47 PM. She acknowledged that the bottle of Latanoprost eye…

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 resident and staff interviews the facility failed to treat a resident in a dignified manner by not providing incontinent care when requested for 1 of 3 residents reviewed for dignity (Resident #1). The Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses of hemiplegia and seizure disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was cognitively intact, required extensive assistance with toileting, and was always incontinent of bladder and bowel. No refusal of care was noted during the assessment reference period. Resident #1 was interviewed in his room on 08/08/23 at 10:30 AM. During the interview he stated he often had to wait 40 minutes or longer on staff to answer his call light when he needed to be changed. Resident #1 stated he had just soiled his brief 5 minutes prior to the surveyor speaking with him and proceeded to press his call light to request assistance from staff. The call light was observed…

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 staff interviews, the facility failed to transmit Minimum Data Set (MDS) assessments within the regulatory timeframe as specified in the Resident Assessment Instrument (RAI) manual for 3 of 21 residents reviewed (Resident #20, Resident #21, and Resident #60). The findings include: 1. Resident #20 was admitted to the facility on [DATE]. A review of Resident #20's most recent quarterly MDS assessment with an Assessment Reference Date (ARD) of 3/24/23 revealed it was transmitted to CMS on 5/18/23. 2. Resident #21 was admitted to the facility on [DATE]. A review of Resident #21's most recent quarterly MDS assessment with an ARD of 1/13/23 showed it was transmitted to CMS on 5/18/23. 3. Resident #60 was admitted to the facility on [DATE]. A review of Resident #60's significant change assessment with an ARD of 3/31/23 revealed it was transmitted to CMS on 5/18/23. An interview on 5/24/23 at 3:42 PM with the MDS Coordinator revealed all MDS assessments with an ARD of 12/1/22 or later had been…

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, resident, staff and Nurse Practitioner interviews, the facility failed to apply compression stockings as ordered by the Nurse Practitioner for 18 days. The failure occurred for 1 of 1 resident (Resident #125) reviewed for the provision of care according to professional standards. The findings included: Resident #125 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, hypertension, protein calorie malnutrition and muscle weakness. Review of Resident #125's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired with no behaviors and could make all his needs known. The assessment also revealed Resident #125 required extensive to total assistance of one staff member with all activities of daily living except eating. Review of a request for treatment note written by Nurse #1 on 05/08/23 revealed Resident #125 had 2+ pitting edema (occurs when excess fluid builds up in body causing swelling;…

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, staff and Medical Director interviews the facility failed to comply with oxygen orders for 1 of 2 residents reviewed for respiratory care (Resident #43). The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, chronic respiratory failure, and dependence on supplemental oxygen. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was not cognitively intact and was coded as receiving oxygen (O2). Review of revised care plan dated 01/13/23 revealed a care plan for oxygen where Resident #43 will not have signs or symptoms of poor oxygen absorption through the review date. Interventions included administer oxygen per orders, assess for signs and symptoms of respiratory distress and reports to physician as needed, monitor oxygen as ordered and/or as needed, monitor tops of ears for redness or breakdown due to use of oxygen tubing, head of bed at least 30 degrees to assist with…

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, resident, and staff interviews, the facility failed to provide a privacy curtain for 1 of 10 rooms on the 300-hall reviewed for privacy. The findings included: Resident #31 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #31 was cognitively intact for decision making. An observation and interview conducted with Resident #31 on 5/22/23 at 4:20 PM revealed Resident #31 was sitting in her wheelchair in front of the television in her pajamas. Resident #31 indicated she had not had a privacy curtain in a few months and when staff assisted her staff would close the roommates' curtain for privacy. Resident #31 stated she had told nursing staff prior and would prefer to have her own privacy curtain. The interview revealed the resident did not recall what staff member she had told and had not been exposed while getting care due to the lack of having a privacy curtain. An interview and observation conducted with Nurse Aide (NA) #1 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.