Lakeview Manor Healthcare Center

In the surveyor’s words

From the most serious findings on record at Lakeview Manor Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 4, 2024

  Based on observation, interview and record review, the facility failed to implement timely interventions to prevent the development of a Stage 3 pressure ulcer for one resident (Resident #18) and an unstageble pressure ulcer for another resident (Resident #30), follow interventions, ensure that physician's treatment orders were followed and documented and prevent the worsening of the Stage 3 pressure ulcer for Resident #18 of three residents reviewed for pressure ulcers, resulting in Resident #18's development and worsening of a Stage 3 pressure ulcer and Resident #30's development of a left heel unstageble pressure ulcer with the likelihood of pain and infection. […]

• Actual harm, isolatedF689Dec 21, 2021

  This Citation Pertains to Intake Numbers MI 477, MI 118, MI 060, MI 132, MI 310, and MI 636 Based on observation, interview and record review, the facility failed to institute and operationalize policies and procedures to ensure adequate supervision and implementation of planned, appropriate, and meaningful interventions to prevent falls in a timely manner for four residents (Resident #8, Resident #158, Resident #159, and Resident #160) of six residents reviewed for falls. This deficient practice resulted in multiple major injuries resulting from falls within the facility including Resident #8 suffering a femur fracture requiring surgical intervention, Resident #158 suffering a fractured femur with essential surgical intervention, Resident #159 fracturing both their sacrum (triangular bone… […]

• No harm, potential for more than minimal, widespreadF880Mar 27, 2025

  Based on observation, interview and record review, the facility failed to implement and operationalize an infection control program including ensuring safe and sanitary conditions in the beauty parlor, comprehensive outcome surveillance, evaluation and analysis of data for potential trends, and identification and monitoring of potential infections for all 57 residents residing in the facility. Findings include: An interview and review of facility Infection Control (IC) data was completed with IC Registered Nurse (RN) C on 3/27/25 at 2:09 PM. Upon request to review IC data for February 2025, RN C provided a written line listing tool, a typed line listing Surveillance Monthly Report, a mapping tool, and a summary form. […]

• No harm, potential for more than minimal, widespreadF812Apr 5, 2023

  Based on observation, interview, and record review the facility failed to ensure accurate and proper thermometer calibration of five of seven thermometers tested in the kitchen, resulting in an increased potential for foodborne illness potentially affecting all 59 residents. Findings include: 1. On 4/2/23 at 11:24 AM, upon interview with the Dietary manager, staff J regarding the frequency in which the facilities thermometers are checked for their accuracy they stated, the cooks check for proper calibration of our thermometers on a weekly basis. We have it as part of our weeks tasks to complete. At this time the surveyor inquired with Cook, staff K, on what method they use to verify the thermometers are proper calibrated to which they responded, with a cup of ice water. […]

• No harm, potential for more than minimal, widespreadF812Dec 21, 2021

  Based on observation, interview and record review, the facility failed to 1) maintain food preparation and kitchen equipment in a sanitary and good working condition, 2) label resident foods with use-by dates, 3) ensure proper drying of food equipment, and 4) ensure no wooden handle food equipment was used in the kitchen, resulting in an increased likelihood for food contamination and food borne illness, with the potential to affect 48 residents in the facility census of 48 who consumed oral nutrition from the facility kitchen of a census of 48. Findings Include: Review of the U.S. […]