Lakeshore Village Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Lakeshore Village Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Dec 16, 2023

  Based on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for 6 of 6 administrative staff responsible for monitoring and implementing the facility policy and procedures for 1 of 1 facility reviewed for Administration. 1. The Medical Director, NP, DON, and ADON failed to monitor routine laboratory results for residents on an anticonvulsant medication for seizure management. 2. The DON and ADON failed to ensure nursing staff had the appropriate competencies related to an LVAD (life-saving device). 3. […]

• Immediate jeopardy, patternF580May 10, 2025

  Based on interview and record review the facility failed to immediately notify Resident #1's Responsible Party and practitioners when there was a significant change the resident's physical status (a deterioration in health) for one of five residents (Resident #1) reviewed for resident rights. The facility failed to inform Resident #1's Responsible Party when he refused to eat or drink from dinner on 4/9/2025 to breakfast on 4/11/2025. The resident was sent to theER on [DATE] with altered mental status, high heart rate resulting in a diagnosis of Acute encephalopathy [altered brain function], Acute renal failure [decreased blood flow to the kidneys] and profound dehydration. […]

• Immediate jeopardy, patternF692May 10, 2025

  Based on interview and record review the facility failed maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not a possible or resident preference indicated otherwise and is offered sufficient fluid intake to maintain proper hydration and health for one of five (Resident #1) residents reviewed for nutrition and hydration. The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 refusing meals and hydration from dinner on 4/9/2025 to breakfast on 4/11/2025. […]

• Immediate jeopardy, patternF726Dec 16, 2023

  Based on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for residents' needs for 8 of 8 nurses (LVN G, E, KK, CCC, GGG, NNN, OOO, and RN D ) reviewed for nursing services. 1. The facility did not ensure nursing staff was trained and educated on the LVAD (a device that is used in the treatment of end-stage heart failure). 2. The facility did not ensure nursing staff was trained on complications to monitor for Resident #231's LVAD. 3. The facility did not ensure nursing staff obtained MAP (average calculated blood pressure in an individual during a single cardiac cycle) pressures and documented them appropriately on the MAR. An IJ was identified on [DATE]. […]

• Immediate jeopardy, patternF770Dec 16, 2023

  Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 5 of 12 residents (Resident's #12, #17, #43, #61, and #65) reviewed for laboratory services. 1. The facility did not ensure Resident #61 had his routine Keppra, Tegretol, and Depakote levels monitored as ordered by the physician. 2. The facility did not ensure Resident #43 had her routine topiramate and Keppra levels monitored as ordered by the physician. 3. The facility did not ensure Resident #12 had her routine primidone and phenobarbital levels monitored as ordered by the physician. 4. The facility did not ensure Resident #65 had her routine Depakote and phenytoin (Dilantin) levels monitored as ordered by the physician. 5. […]