Lakeshore Rehabilitation Center LLC

Inspectors wroteBased on interview and document review, the facility failed to provide sufficient nursing staff to ensure 13 of 13 residents (R7, R4, R13, R31, R45, R35, R37, R42, R29, R35, R8, R24, R33), reviewed for sufficient staffing, received care and assistance in a timely manner. The lack of sufficient staff had the potential to affect all 42 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Facility Assessment included information on staffing levels needed for specific shifts. This deficient practice had the potential to affect all 42 residents who resided in the facility.

Inspectors wroteBased on interview and record review, the quality assurance and performance improvement (QAPI) committee failed to identify resident call light wait time concerns prior to survey, nor make a good faith attempt to correct the deficiency. This deficient practice had the potential to affect all 42 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to develop and implement action plans, measure the success of actions and track performance, conduct a performance improvement project (PIP), and regularly review, analyze, and act on data collected. This deficient practice had the potential to affect all 42 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident concerns identified at resident council meetings were addressed and residents notified of a resolution or ongoing measures to ensure compliance. This affected all 9 residents (R8, R24, R25, R28, R29, R30, R33, R35, and R36) who attended resident council.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment for residents residing in East and [NAME] hallways resulting in large dark stains, fraying and worn carpet throughout the hallway and damaged, cracked, sagging, and discolored ceiling tiles in the east hallway bath tub room. Findings Include: On 7/13/26 at 5:09 p.m., observation of the east hallway outside resident rooms identified a discolored dark stain on the flooring measuring approximately 11/2 feet by 6 inches, irregularly shaped with darkened edges and concentrated areas of discoloration. The stains were distributed throughout the hallway and were readily visible from a distance due to the contrast between the stained areas and the surrounding carpet. The carpeting appeared worn and soiled. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure the Minimum Data Set (MDS) assessment was coded accurately for 1 of 1 resident (R50) reviewed for discharge a by inaccurately coding a planned discharge as an unplanned discharge, and failed to follow the Resident Assessment Instrument (RAI) Manual.

Inspectors wroteBased on interview, observation, and document review, the facility failed to provide the necessary assistance with activities of daily living (ADL) to maintain oral hygiene for 1 of 2 residents (R42) reviewed for ADL assistance.

Inspectors wroteBased on interview and document review, the facility failed to provide oral care to 1 of 1 resident (R13) who was reviewed for assistance with activities of daily living (ADLs) and who was dependent upon staff for ADL cares.

Inspectors wroteBased on interview and document review, the facility failed to implement a bowel movement (BM) protocol for 1 of 1 resident (R13) reviewed for constipation.

Inspectors wroteBased on interview and document review, the facility failed to maintain, restore or improve the functional ability for 2 of 2 residents (R29, R37) reviewed for ADLs, when the facility failed to ensure residents were walked according to physical therapy (PT) instructions and physician orders.

Inspectors wroteBased on observation, interview, and document review the facility failed to maintain reusable resident care equipment in a manner that could be effectively cleaned and disinfected by continuing to use a bathtub chair with torn and cracked cushion surfaces in the east hallway bath room. This had the potential to affect any of the 19 residents residing on the east and west hallways who used the tub room.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the posted nursing hours were updated when there was a change to staffing levels. This had the potential to affect all residents and visitors of the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers, failed to ensure food stored in the refrigerators and dry storage were labeled, dated and discarded properly. This deficient practice had the potential to affect all 48 residents, staff and visitors who received food from facility kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R35) reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with facial hair removal for 1 of 1 resident (R35) reviewed for activities of daily living (ADL')s .

Inspectors wroteBased on observation, interview, and document review, the facility failed to monitor orthostatic blood pressures for 3 of 3 residents (R7, R8, and R32) and failed to ensure residents were routinely assessed for side effects who received physician ordered antipsychotic medications for 1 of 5 residents (R8), reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identify, investigate, analyze and respond to freezer maintenance (i.e., prevent ice buildup) by developing and implementing action plans for the process improvement identified to be a current concern with past identified non compliancy. This had potential to affect all 45 residents, staff and visitors who consumed food at the care center.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers using the main production kitchen. This had potential to affect all residents who could potentially consume the items.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were assessed for appropriateness to be assisted by paid feeding assistants (PFA)'s at meals including residents with or without difficulty swallowing and/or with complicated feeding problems requiring a mechanically altered diet and/or special precautions for 6 of 6 residents (R4, R5, R6, R10, R16, and R30) reviewed. The facility also failed to ensure the PFA's were supervised at all times by a nurse while performing feeding assistance.

Inspectors wroteBased on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 4 of 5 residents (R3, R2, R8, R24) reviewed for immunizations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dignified, personal space was maintained for 1 of 1 resident (R8) who had staff enter their room without knocking or waiting for a response. In addition, the facility failed to ensure a dignified, homelike dining experience was provided for 1 of 1 resident (R29) observed to wait for an extended period of time for their meal despite tablemate's being served.

Inspectors wroteBased on interview and document review, the facility failed to comprehensive assess and, if needed, develop interventions to ensure an appropriate, proactive bowel management program was implemented to promote comfort for 1 of 1 resident (R31) reviewed who complained about constipation.