Lakeside Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Lakeside Health & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Sep 10, 2025

  Based on observation, interview, and record review, the facility failed to assess, monitor, and provide interventions to prevent decannulation for a resident with known behaviors of self-decannulation; and failed to ensure that staff were provided tracheostomy recannulation education for extubation for 1 of 2 residents (R3) reviewed for tracheostomy in the sample of 2. The failure resulted in R3's self-decannulation of her tracheostomy which compromised R3's health status. R3 required emergency transfer to the local hospital on [DATE] and required two attempts at reinsertion of the tracheostomy and arterial line placement. After reinsertion of R3's tracheostomy by an ENT physician, R3 became hypoxic with oxygen saturation in the 80's and had increased work for breathing. […]

• Actual harm, isolatedF677May 26, 2026

  Based on observation, interview, and record review the facility failed to provide timely and complete incontinent care for 2 (R7 and R15) of 2 residents reviewed for Activities of Daily Living (ADL) care in a sample of 29, this failure resulted in R7 and R15 expressing feelings of worry, anxiety, and being upset.Findings Include:1.)R7's Undated Face Sheet documents R7 was admitted to the facility on [DATE] and has a medical diagnosis of Chronic Respiratory Failure with Hypoxia, Chronic Systolic Congestive Heart Failure, Hypertension, Type 2 Diabetes Mellitus, and Displaced Trimalleolar Fracture of Right Lower Leg.R7's Minimum Data Set (MDS) dated [DATE] documents R7 is cognitively intact, is dependent on staff for toileting hygiene, and is frequently incontinent of bladder. […]

• Actual harm, isolatedF684May 26, 2026

  Based on interview and record review, the Facility failed to provide timely emergency room (ER) transport for 1 of 1 residents (R61) reviewed for quality of care in the sample of 29. This failure resulted in R61 not being sent to the ER for more than eight hours after receiving the physician order. R61 decompensated later that day and required oral intubation.Findings include: 1-R61's Face Sheet documents R61 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV), toxoplasma meningoencephalitis, cryptococcosis, and streptococcal pneumonia. R61's Minimum Data Set (MDS) dated [DATE] documented R61 was cognitively intact and required partial assistance with bed mobility and transfer. 05/20/2026 10:03 AM, R61 was sitting up in his bed. […]

• Actual harm, isolatedF690May 26, 2026

  Based on observation, interview, and record review, the facility failed to provide appropriate nephrostomy care to prevent infections in 1 of 2 residents (R10), reviewed for bowel/bladder incontinence, catheters, and UTIs (Urinary Tract Infections) in the sample of 29. This failure resulted in R10 having multiple UTIs with hospitalization. Finding Include:On 5/20/26 at 10:40 AM, nephrostomy care was observed with V21, Wound Nurse, with the following noted: Prior to entering room, V21 donned a gown, gloves, and mask. V21 entered the room and removed the left nephrostomy dressing, dated 5/19/26, and discarded it in the regular trash can. There were no gloves available in the room, V21 exited the room and brought in a box of gloves. V21 donned the gloves with no hand hygiene completed. […]

• Actual harm, isolatedF880May 26, 2026

  Based on observation, interview, and record review, the facility failed to utilize infection control techniques in 5 of 5 residents (R3, R7, R10, R15, R28), reviewed for infection control in the sample of 29. This failure resulted in R10 having multiple UTI's (Urinary Tract Infections) with hospitalization. Findings Include: 1) On 5/20/26 at 10:40 AM, nephrostomy care was observed with V21, Wound Nurse, with the following noted: Prior to entering room, V21 donned a gown, gloves, and mask. V21 entered the room and removed the left nephrostomy dressing, dated 5/19/26, and discarded it in the regular trash can. There were no gloves available in the room, V21 exited the room and brought in a box of gloves. V21 donned the gloves with no hand hygiene completed. […]