Lakeside Special Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF689Feb 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure a licensed nurse checked the meal trays for nine residents in Cottage Two during dining observation. This failure put residents at risk of receiving the incorrect diet based on their medical needs. Findings: On 2/10/25 at 12:08 P.M., a lunch observation was conducted. A Staff Member (SM) was observed pushing a cart from the hallway to the dining area, calling out, Appetizer is here .Appetizer is here! The SM parked the cart inside the dining room. Residents were seated in the dining room and a female resident left the dining area to call another residents. Nine residents were seated in the dining table and were served with the appetizer [cantaloupe] and drinks. […]

• No harm, potential for more than minimal, patternF812Feb 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure food stored and prepared in the kitchen was in accordance with standards of practice when food items were not labeled. In addition, the temperature log was incomplete, and there was an icicle build-up in the reach-in freezer. These failures could cause food-borne illness, and icicle build-up may affect the food's palatability and texture. Based on observation, interview, and record review, the facility failed to ensure storage of food items inside the refrigerator were labeled. In addition, the temperature log was not completed, and the freezer was not maintained in a sanitary manner. These failures had the potential to cause food-borne illness and may affect the texture and palatability of food. […]

• No harm, potential for more than minimal, isolatedF689Aug 25, 2026

  Based on observation, interview, and record review, the facility failed to follow their policy on visitor check-in procedure when a staff employee allowed a non-staff employee enter the gate and left unsecured. This resulted in Resident 1 exiting the gate and eloped (a resident leaves the facility premises or a secured area without the knowledge, or supervision of the staff). This deficient practice threatened the safety and well-being of Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnoses which included Bipolar Disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, and activity levels), current episode manic (a psychological state defined by a persistent spike in mood, high energy, and extreme activity that lasts for… […]

• No harm, potential for more than minimal, isolatedF758Feb 13, 2025

  Based on interview and record review, the facility failed to ensure two of four residents (Resident 14 and Resident 21) reviewed for antipsychotic (a class of drugs that treat symptoms of mental disorder by altering brain function) medication use had an approved indication. This failure had the potential to result in unnecessary use of psychotropic medication. Findings: 1. Resident 21 was readmitted to the facility on [DATE] with diagnoses which included schizoaffective (a mental health condition that may interfere with a resident's ability to think, manage emotions, make decisions, and relate to others) disorder per the Admission Record. A review of Resident 21's medical record was conducted. […]

• No harm, potential for more than minimal, isolatedF842Feb 13, 2025

  Based on interview and record review, the facility failed to ensure a resident's medical record was completed for one of 23 sampled residents (Resident 99) when the licensed nurse (LN) did not document that the physician was notified of the resident's refusal for chest X-ray (CXR- an imaging test to create a picture of the structures in the chest, including the lungs, heart, and rib cage). As a result, Resident 99's medical record did not provide continuity of care between the care team. Findings: Resident 99 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), per the Admission Record. Per the same document, Resident 99 was transferred to the hospital on 12/22/24. A review of Resident 99's medical record was conducted. […]