Lakeshore Manor Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Lakeshore Manor Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF607Mar 14, 2026

  Based on observations, interviews, and record reviews, the facility failed to implement its written abuse policy to prevent resident abuse, neglect, exploitation and misappropriation of property by failing to ensure employment screening was completed for 1 (S12) of 1 unknown alleged agency staff. On [DATE], S12, who was not employed by the facility or staffing agency, was assigned to provide direct care to residents R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10 without being screened for a history of abuse, neglect, exploitation or misappropriation of property. An Immediate Jeopardy situation began on [DATE] at 8:00 a.m. […]

• Immediate jeopardy, widespreadF835Mar 14, 2026

  Based on observations, interviews, and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to ensure an effective screening and onboarding system was developed and implemented to prevent 1(S12) of 1 unknown alleged agency staff from being assigned to provide direct resident to residents R1, R2, R3, R4, R5, R6, R7, R8, R9 and R10. This deficient practice had the potential to affect any of the 83 residents residing in the facility that received direct care from nursing personnel. An Immediate Jeopardy situation began on 03/12/2026 at 8:00 a.m. […]

• Immediate jeopardy, widespreadF684Aug 8, 2023

  Based on observations, interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure: 1.) Nurses administered medications as ordered for 7 (#1, #2, #3, #4, #R1, #R2, and #R3) of 8 (#1, #2, #3, #4, # 5, #R1, #R2, and #R3) residents reviewed; 2.) Changes in Respiratory orders were communicated with Respiratory staff for 2 (#3 and #R1) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; and 3.) Physician's Orders were followed for 4 ( #1, #2, #3, #R2 and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed. […]

• Immediate jeopardy, widespreadF726Aug 8, 2023

  The facility failed to ensure licensed nurses and other nursing personnel had the knowledge, competencies, and skill sets to provide care and respond to each resident's individualized needs by failing to ensure: 1.) Nurses administered medications as ordered for 7 (#1, #2, #3, #4, #R1, #R2, and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; 2.) Changes in Respiratory orders were communicated with Respiratory staff for 2 (#3 and #R1) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed; and 3.) Physician's Orders were followed for 4 ( #1, #2, #3, #R2 and #R3) of 8 (#1, #2, #3, #4, #5, #R1, #R2, and #R3) residents reviewed. […]

• Immediate jeopardy, widespreadF835Aug 8, 2023

  47173 Based on observations, interviews and record reviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident. The facility failed to ensure a functional system was in place to acquire, receive, transcribe, and implement accurate physician orders for 7 ( #1,#2,#3,#4, #R1, #R2, #R3) out of 8 ( #1, #2, #3, #4, #5, #R1, #R2, #R3) residents reviewed. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a dependent resident with an infected Stage 4 Sacral Wound, on 06/13/2023 at 2:30 p.m. when nursing staff failed to communicate a new Physician's Order for intravenous Vancomycin to the pharmacy. […]