Lakeside Manor Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lakeside Manor Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF693Apr 5, 2022

  Based on observation, interview, and record review, the facility was placed in Immediate Jeopardy (IJ) related to failing to ensure that medically complicated residents receiving enteral nutrition (tube feeding) and at risk for weight loss, dehydration, and aspiration (inhalation of foods/fluids into the lungs) were thoroughly assessed, evaluated, and monitored by a Registered Dietitian (RD) as well as provided care by competent staff to prevent complications, effecting six Residents (#15, #43, #46, #901, #902, #903) out of six Residents reviewed for enteral nutrition. […]

• Immediate jeopardy, isolatedF689Aug 19, 2022

  This citation pertains to Intakes: MI 936, MI 989, MI 009, MI 142, MI 425, and MI 451. Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement from the facility for one sampled Resident (R901), noted with severe cognitive impairment and known high risk elopement history resulting in, R901 exiting the facility through the North side door of the building unbeknownst to staff, located near a busy road, during the evening approximately one mile away by a non-facility staff member and after notification retrieved by the Director of Nursing (DON). This deficient practice resulted in an immediate jeopardy, with the likelihood of serious injury, harm, impairment, or death. […]

• Immediate jeopardy, isolatedF689Nov 23, 2021

  This citation pertains to intake #MI 307. Based on observation, interview and record review the facility failed to provide monitoring and/or supervision to prevent elopement and respond to an alarm sounding door for one Resident (Resident #708) of four residents reviewed for elopement, resulting in immediate jeopardy (IJ) due to the likelihood of serious injury, harm, impairment or death. On 11/12/2021 at approximately 06:31 AM, Resident #708 was witnessed by Resident #711 outside of the facility trying to get back in. Resident #708 had exited the facility from an emergency door, unbeknownst to the staff, dressed in flannel pajama bottoms, a T-shirt, and socks, with an approximate outdoor temperature of 39 degrees Fahrenheit. […]

• Immediate jeopardy, isolatedF600Aug 19, 2021

  This citation pertains to Intakes MI 035, MI 950, MI 883 and MI 928 Based on observation, interview and record review, the facility failed to monitor, supervise, and provide an environment free from sexual abuse for one Resident (R900) of two sampled residents reviewed for sexual abuse, which began on 8/8/2021 between the hours of 10:00 PM and 11:00 PM when Resident (R901) was observed on top of Resident (R900) moving up and down in a sexual motion. This deficient practice resulted in an Immediate Jeopardy (IJ) and the likelihood for serious sexual and/or psychosocial harm (based on the reasonable person), injury, impairment or death. Findings include: A review of the complaint dated 8/10/21 noted the following: (R900) is diagnosed with Dementia. […]

• Actual harm, patternF692Apr 5, 2022

  Based on observation, interview, and record review, the facility failed to ensure that Residents were: 1) provided feeding assistance and supervision per assessment; 2) Provided fluids of appropriate consistency to prevent dehydration; 3) assessed and monitored by a qualified nutritional professional to maintain adequate nutritional parameters and to address significant weight loss, and; 4) were weighed per physician order to monitor weight status for seven Residents (#6, #27, #43, #95, #145, #902, and #903) out of 17 reviewed for nutrition and hydration. This deficient practice resulted in significant weight loss, a lack of weight monitoring, and a lack of assessment with the potential for dehydration, tube feeding intolerance, and overall decline. […]