Lakeshore Post Acute and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lakeshore Post Acute and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 9, 2023

  Based on observations, record review and interviews, the facility failed to ensure interventions were carried out or offered to prevent pressure injury from occurring for two (#1and #2) of four out of 10 residents. Specifically, -Resident #1 was at high risk for pressure injury when she entered the facility. The facility failed to encourage the resident to reposition, As a result the resident developed an unstageable pressure injury to her right heel. The facility failed to ensure treatments were provided as ordered by the physician and develop a person-centered care plan for the resident's pressure injury to the right heel. Additionally the facility failed to ensure: -Resident #2 was not repositioned timely and physician orders were not followed. Findings include: I. […]

• Actual harm, isolatedF692Mar 9, 2023

  Based on observations, record review and interviews, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for four (#1, #3, #5 and #9) of four out of ten residents. Specifically, the facility failed to: -Ensure Resident #1 was offered hydration on a consistent basis or encouraged to accept hydration per assessed daily minimum recommendation (see nutrition assessment below). Although Resident #1'ss risk for dehydration was identified upon admission, the facility failed to implement measures to ensure the resident received sufficient fluids to maintain hydration needs. As a result, of the resident poor fluid intake Resident #1 had a change of condition prompted by lack of hydration. […]

• No harm, potential for more than minimal, widespreadF812Oct 26, 2023

  Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; and, -Beard restraints were worn in kitchen areas while serving food. Findings include: I. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. […]

• No harm, potential for more than minimal, patternF921Aug 28, 2025

  Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident rooms, shower rooms and hallways received necessary maintenance and repairs. Findings include:I. Observations On 8/26/25 at 10:20 a.m., observations of the facility revealed the following:In the shower room on the A hall, it was revealed that there was a missing vent, leaving a hole in the ceiling.-The ventilation system in the A Hall shower room was not working The vents on the A hall and B hall were rusty with a brown colored substance around the surfaces, and the vents were missing paint.A hole was observed in the drywall of room F-4.On Hall C, room [ROOM NUMBER] had water… […]

• No harm, potential for more than minimal, patternF655Feb 26, 2025

  Based on record review and interviews the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for three (#3, #11 and #14) of four residents reviewed for baseline care plans out of 22 sample residents. Specifically, the facility failed to ensure pertinent medical information was included on Resident #3, Resident #11 and Resident #14's baseline care plans within 48 hours of admission. Findings include: I. Facility policy and procedure The Comprehensive Person-Centered Care Planning, revised January 2022, was received from the nursing home administrator (NHA) on 2/26/25 at 5:08 p.m. […]