Lakeview Manor Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600Apr 21, 2022

  Based on interviews and record reviews, the facility failed to ensure the residents were free from neglect and verbal abuse by failing to ensure: 1. 1 (#77) of 6 (#7, #52, #57, #61, #65, and #77) residents reviewed for accidents received the necessary care and services to manage pain and provide timely treatment after a fall resulting in a hip fracture; and 2. S24CNA did not verbally abuse 1 (#55) of 2 (#55 and #59) residents reviewed for abuse. This deficient practice resulted in an actual harm on 03/20/2022 at 04:00 p.m. when Resident #77, a cognitively impaired resident, was found on the floor and transferred into the bed by S10LPN and S12CNA. Resident #77 exhibited signs of pain during the transfer. An order was implemented for a STAT (immediately) right hip x-ray. […]

• No harm, potential for more than minimal, widespreadF812Apr 21, 2022

  Based on observations, interviews, and record review, the facility failed to store and prepare food under sanitary conditions by failing to ensure: 1. Food was properly stored and labeled in the refrigerator of the facility's kitchen; 2. Food was properly stored and labeled in the walk-in food storage room of the facility's kitchen; 3. Milk was served at safe temperatures; 4. There was a working thermometer to check cold food temperatures This deficient practice had the potential to affect 83 residents who were served meals from the facility's kitchen. Findings: Review of facility policy titled Refrigerators & Snacks/Supplements Handling revealed the following: Temperatures must be maintained at the following F (Fahrenheit) settings for the items indicated below: a. […]

• No harm, potential for more than minimal, patternF740Apr 15, 2026

  Based on observations, interviews and record reviews, the facility failed to have a system in place to provide individualized behavioral health services, which met the individualized needs of a resident by preventing and treating their mental health disorder(s) for 1 (#17) of 7 residents reviewed for behavioral health in the sample Findings: Review of the facility's undated Provision of Quality Care Policy, as of 04/15/2026 at 3:45 p.m., revealed, in part, the following: Policy Explanation and Compliance Guidelines: 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 3. Qualified persons will provide the care and treatment in accordance with the resident's choices. 6. […]

• No harm, potential for more than minimal, patternF812Apr 15, 2026

  Based on observations, interviews, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. Food was labeled and / or dated with a preparation date; and 2. Left over food was discarded in a timely manner.This deficient practice had the potential to affect any of the 91 residents who received nourishment from the facility's kitchen.Findings: Review of the undated facility policy titled Storage: Freezer revealed the following, in part:3. Label and date all items Review of the undated facility policy titled Storage: Refrigerator revealed the following, in part:6. If raw foods must be kept in the same refrigerator keep cooked foods above raw foods. […]

• No harm, potential for more than minimal, patternF656Mar 12, 2025

  Based on observation, interviews, and record review, the facility failed to ensure a resident's comprehensive person-centered care plan was implemented by failing to administer enteral feeding as ordered for 1 (#53) of 2 (#53 and #71) residents reviewed with enteral feeding. Findings: Review of Resident #53's Clinical Record revealed he admitted to the facility on [DATE] and had diagnoses, which included Neurocognitive Disorder with Lewy Bodies, Gastrostomy Status, and Dysphagia. Review of Resident #53's Significant Change MDS with an ARD of 01/08/2025 revealed a BIMS interview was not conducted related to the resident was rarely/never understood. […]