Lakeside Rehabilitation and Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Feb 11, 2021

  Based on policy review, observation, and staff interview, it was determined the facility failed to ensure a) Designated staff were assigned each shift to work only with COVID-19 positive residents to prevent the transmission of COVID-19 and b) respiratory equipment was cleaned and disinfected following manufacturer instructions. The facility's failure to maintain infection control measures to prevent facility transmission placed all residents in the facility and staff working in the facility who tested negative for COVID-19 or whose COVID-19 status was unknown at risk for serious harm, impairment, and/or death related to COVID-19. […]

• Actual harm, patternF600Oct 11, 2024

  Based on observation, record review, policy review, review of the State Survey Long-Term Care Reporting Portal and interviews, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 6 of 8 residents (#4, #18, #20, 26, 46 and #56) reviewed for abuse and neglect. These deficient practices resulted in residents being subjected to neglect, abuse, and ongoing verbal abuse with the potential for physical and/or psychosocial harm. Findings include: -Residents #4, #20, #26, and #46 experienced mental and psychosocial harm when they were verbally abused by Resident #61. - Resident #56 experienced neglect when she did not receive wound care for a pressure ulcer. - Resident #18 experience physical harm from the facility staff during cares. […]

• Actual harm, isolatedF760Oct 18, 2023

  Based on record review, review of the State Long-Term Care Reporting Portal, review of facility policies, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This affected 1 of 6 residents (Resident #1) reviewed for medication administration. Resident #1 was harmed when she did not receive 13 doses of short-acting insulin for 4 consecutive days and required hospitalization for emergency treatment for hyperglycemia. Findings include: The facility's Physician's Orders policy, revised on [DATE], documented a nurse will confirm accuracy of orders by leaving new or changed orders in the queue for a second licensed nurse to verify. […]

• Actual harm, isolatedF684Feb 11, 2021

  Based on observation, record review, and resident and staff interview, it was determined the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 3 of 7 residents (#2, #4, and #6) whose records were reviewed. This resulted in a lack of needed care and services to meet residents' needs and resulted in harm to Resident #2 when she developed acute aspiration pneumonia and acute [MEDICAL CONDITION] resulting in hospitalization . Findings include: The facility's Episodic Charting procedure, undated, stated significant resident care issues were to be documented until stabilized or resolved. […]

• No harm, potential for more than minimal, widespreadF585Nov 3, 2023

  Based on policy review, review of grievances, and staff interview, it was determined the facility failed to ensure resident grievances were investigated and resolutions were documented. This deficient practice placed all residents at risk of having unmet needs and poor quality of life when their concerns were not properly addressed. Findings include: The facility's grievance policy, revised 1/27/23, stated the Grievance Officer supervised and documented the details of the investigation and resolution of grievances. This policy was not followed. On 10/31/23 at 2:00 PM, residents at the resident council meeting stated they were unhappy with the facility's grievance process. They explained when they submitted a grievance, they did not know how the facility was addressing their concerns. […]