Lakeside Health & Rehab Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sufficient number of CNAs (Certified Nursing Assistants) to provide timely care to the residents in the sample of 29, when reviewed for sufficient staffing. This failure has the potential to affect all 54 residents residing in the facility. Findings Include:On 5 /19/26 at 9:36 AM, R7 pressed the call light button due to being incontinent of urine. R7 stated she is unsure how long she was been wet because she fell asleep, but she is wet now. R7 stated she is left in a wet depends for extended periods of time and has waited over 30 minutes for her call light to be answered by staff to help her. On 5/19/26 at 9:40 AM, V22, Activity Aide, walked into R7's room and asked what R7 needed. V22 walked out of R7's room with R7's call light still on. [...]

Inspectors wroteBased on interview and record review, the Facility failed to provide timely emergency room (ER) transport for 1 of 1 residents (R61) reviewed for quality of care in the sample of 29. This failure resulted in R61 not being sent to the ER for more than eight hours after receiving the physician order. R61 decompensated later that day and required oral intubation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate nephrostomy care to prevent infections in 1 of 2 residents (R10), reviewed for bowel/bladder incontinence, catheters, and UTIs (Urinary Tract Infections) in the sample of 29. This failure resulted in R10 having multiple UTIs with hospitalization. Finding Include:On 5/20/26 at 10:40 AM, nephrostomy care was observed with V21, Wound Nurse, with the following noted: Prior to entering room, V21 donned a gown, gloves, and mask. V21 entered the room and removed the left nephrostomy dressing, dated 5/19/26, and discarded it in the regular trash can. There were no gloves available in the room, V21 exited the room and brought in a box of gloves. V21 donned the gloves with no hand hygiene completed. [...]

Inspectors wroteBased on interview and record review, the Facility failed to obtain and properly administer prescribed medications for 2 of 3 residents (R15, R61) reviewed for pharmacy services in the sample of 29. This failure resulted in R61 missing three doses of a prescribed intravenous (IV) medication and being transported to the hospital where he required intubation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize infection control techniques in 5 of 5 residents (R3, R7, R10, R15, R28), reviewed for infection control in the sample of 29. This failure resulted in R10 having multiple UTI's (Urinary Tract Infections) with hospitalization. Findings Include: 1) On 5/20/26 at 10:40 AM, nephrostomy care was observed with V21, Wound Nurse, with the following noted: Prior to entering room, V21 donned a gown, gloves, and mask. V21 entered the room and removed the left nephrostomy dressing, dated 5/19/26, and discarded it in the regular trash can. There were no gloves available in the room, V21 exited the room and brought in a box of gloves. V21 donned the gloves with no hand hygiene completed. V21 then proceeded to clean the left nephrostomy tube injection site and flushed it with normal saline as ordered. [...]

Inspectors wroteBased on interviews, observations, and record review, the facility failed to report a fall timely, follow fall incident procedures, and use gait belts during transfers for 3 of 5 residents (R1, R2, R3); reviewed for Quality of Care in a sample of 6. This failure resulted in R2 being moved before a nurse's assessment and delayed treatment for that R2 succumbed multiple pelvic fractures from later requiring surgery.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe transfer for 1 of 1 resident (R6) reviewed for accidents in the sample of 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, and provide interventions to prevent decannulation for a resident with known behaviors of self-decannulation; and failed to ensure that staff were provided tracheostomy recannulation education for extubation for 1 of 2 residents (R3) reviewed for tracheostomy in the sample of 2. The failure resulted in R3's self-decannulation of her tracheostomy which compromised R3's health status. R3 required emergency transfer to the local hospital on [DATE] and required two attempts at reinsertion of the tracheostomy and arterial line placement. After reinsertion of R3's tracheostomy by an ENT physician, R3 became hypoxic with oxygen saturation in the 80's and had increased work for breathing. [...]

Inspectors wroteBased on observation, interview and record review the Facility failed to maintain residents' well-being and dignity by accommodating preference for 4 of 5 residents (R1, R2, R4, and R5) reviewed for accommodation of needs in the sample of 6.

Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to implement preventative measures to reduce the development of and worsening of pressure injuries in 2 of 7(R55, R39) residents in the sample of 31. This failure resulted in R55's skin on 1/7/25 documented as mid buttocks maceration to a developed and documented sacrum pressure ulcer stage 3 on 1/16/25; and other in house developed pressure wounds. R39 also developed several in-house pressure injuries.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide progressive interventions and to prevent multiple falls for 1 of 5 (R47) residents investigated for accidents in a sample of 31. The failure resulted in R47 sustaining a right hip fracture and then sustaining a right hip surgical incision dehiscence requiring a return to the hospital for sutures and antibiotics.

Inspectors wroteBased on interview and record review, the facility failed provide sufficient nursing staff to meet the needs of the residents residing in the facility when reviewed for Sufficient Staffing in the sample of 31. This failure has the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date two opened multi-dose vials of Tuberculin Serum when reviewed for medication storage and labeling. This failure has the potential to affect all 62 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility opened a package belonging to a resident without their permission for 1 of 3 residents (R2) reviewed for Communication with Privacy in the sample of 31.

Inspectors wroteBased on interview and record review, the Facility failed to report an injury of unknown origin for 1 of 1 resident (R265) reviewed for abuse in the sample of 31.

Inspectors wroteBased on interview and record review, the Facility failed to investigate an injury of unknown origin in a timely manner for 1 of 1 resident (R265) reviewed for abuse in the sample of 31.

Inspectors wroteBased on interview, observation, and record review, the Facility failed to ensure enteral feeding was administered in a manner that prevents foodborne illness for 1 of 4 residents (R10) reviewed for nutrition in the sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to identify resident specific behaviors and develop a behavioral care plan with individualized interventions for residents with behavioral health needs for 3 of 6 residents (R2, R3, R8) reviewed for behavioral health services in the sample of 10.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent injury to R2's right second toe during transport to the facility from the hospital. This failure resulted in R2's right toe striking the plate at the bottom of door, causing a wound to the second toe of right foot and toenail being removed.

Inspectors wroteBased on observation, record review and interview the facility failed to provide timely assessment and treatment for a wound for 1 of 5 residents (R2) reviewed for quality of care in the sample of 7.

Inspectors wroteBased on interview, observation and record review the facility failed to respond to call lights timely for 4 of 6 residents (R2, R3, R5, R6) reviewed for accommodation of needs in the sample of 6.

Inspectors wroteBased on interview, observation, and record review, the facility failed to don appropriate Personal Protectant Equipment (PPE) when caring for isolation residents, failed to educate visitors on proper PPE usage during a COVID-19 outbreak, and failed to supply PPE for staff and visitors. This failure has the potential to affect all 57 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement appropriate care plan interventions to prevent falls for 1 of 4 (R6) residents reviewed for falls in the sample of 16.

Inspectors wroteBased on interview, observation, and record review, the facility failed to prevent, identify, assess, monitor, implement progressive interventions, and to handle soiled pressure ulcer dressings appropriately to prevent pressure ulcers and encourage healing for 2 of 3 residents (R2, R3) reviewed for pressure ulcers in the sample of 6. This failure resulted in R2 going for 9 days without a treatment in place for a left heel pressure ulcer and R3 having one pressure ulcer on the left medial foot that was unknown by staff, one pressure ulcer on the left great toe that did not receive treatment or a full assessment for 9 days and R3 developing osteomyelitis requiring Intravenous Antibiotics.

Inspectors wroteBased on interview, observation and record review the Facility failed to provide a RN (Registered Nurse) 8 hours a day 7 days a week. This has the potential to affect all 51 residents of the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to post nurse staffing information. This has the potential to affect all 51 residents of the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to implement care plan interventions related to falls after a resident was moved to a new room for 1 of 3 residents (R19) reviewed for falls/accidents in a sample of 30.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fall interventions were in place to prevent further falls for 1 of 3 residents (R19) who were reviewed for falls/accidents in a sample of 30.

Inspectors wroteBased on interview and record review, the Facility failed to justify why a Gradual Dose Reduction (GDR) was not attempted per a pharmacy recommendation; and, failed to ensure the resident had the proper diagnosis for the psychotropic medications for 2 of 6 residents, (R4, R28) reviewed for unnecessary medications in the sample of 30.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure medications were stored safely until administration and not left at bedside for 1 of 16 residents (R4) reviewed for medication storage in the sample of 30.

Inspectors wroteBased on interview and record review the facility failed to obtain stool for occult for 1 of 6 residents (R47) reviewed for labs in the sample of 30.

Inspectors wroteBased on observation, interview and record review, the Facility failed to use hand hygiene between glove changes prior to entering an Enhanced Barrier Precaution room; and, failed to utilize gloves while in the Enhanced Barrier Precaution room and while touching surfaces with potential bodily fluid contamination for 2 of 24 residents (R4 and R15) reviewed for infection control in the sample of 30.

Inspectors wroteBased on interview, and record review, the facility failed to notify the physician of the inability to administer an antibiotic as ordered for one of one resident (R2) reviewed for physician's notification in the sample of 3.

Inspectors wroteBased on interview, and record review, the facility failed to administer antibiotic as ordered by physician to treat a urinary tract infection (UTI) for one of three residents (R2) reviewed for UTI in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to follow Physician's hospital discharge orders for a high-risk anticoagulant medication for 1 of 2 residents (R49) reviewed for anticoagulant medications in the sample of 27. This failure resulted in R49 receiving double the ordered dose of Eliquis for three days and being hospitalized for 11 days with the diagnosis of Severe Blood Loss Anemia, Acute on Chronic with a differential diagnosis of GI (Gastrointestinal) Bleed, AAA (Abdominal Aortic Aneurysm), and Autolysis.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform complete incontinent care for 4 of 6 residents, (R4, R16, R51 and R156) reviewed for Urinary Tract Infections, (UTI), in the sample of 27.

Inspectors wroteBased on interview and record review, the Facility failed to follow their policy to track COVID-19 vaccination for staff and ensure all staff are fully vaccinated or have a religious or medical exemption. This has the potential to affect all 53 residents living in the Facility.