Lakeside Manor Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly transfer one resident (901) of one reviewed for transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the exterior trash refuse area in a sanitary manner. This deficient practice had the potential to affect all residents, staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to put on and take off personal protection equipment for one (R5) of eight residents with an Enhanced Barrier Precaution (EBP) sign on room door and did not provide adequate Personal Protection Equipment (PPE) for four resident rooms with PPE equipment located in resident rooms; and failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply heel boots for three residents (R2, R4, and R13) out of four reviewed for skin conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall interventions for one resident (R4) out of three reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan to reflect accurate transfer status for one resident (R2) out of three reviewed for falls.

Inspectors wroteThis pertains to intakes 2723857 and 2717388 Based on interviews and record review, the facility failed to provide adequate monitoring and supervision for two residents (R38 and R44) of two residents reviewed for monitoring and supervision. R38On 2/06/2026 at 10:30 AM, R38 was observed ambulating in the hallway. R38 could not recall alleged incident or the name of the facility. A review of R38's medical record revealed that they were admitted into the facility on 9/26/23 and readmitted on [DATE] with diagnoses that included Dementia; Hypertension and Failure to Thrive. A review of R38's Minimum Data Set assessment revealed that the resident was cognitively impaired and required assistance for Activities of Daily Living. R44On 2/06/2026 at 11:30 AM, R44 was observed sitting in a chair in his room with his oxygen nasal cannula on. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to empty a catheter drainage bag for one resident (R2) out of one reviewed for indwelling catheters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistive devices and utensils for eating for one resident (R4) out of two reviewed for limited range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the exterior trash refuse area in a sanitary manner. This deficient practice had the potential to affect all residents, staff and visitors.

Inspectors wroteBased on interview and record review the facility failed to ensure quarterly Quality Assurance (QA) meetings (for identification of any deficiencies and for performance improvement) were held in 2024 for 59 residents in a census of 59.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms, and the north and south resident hallway carpets were clean and in good repair for four residents (R17, R47, R9, R1) in a census of 59.

Inspectors wroteThis citation pertains to intake 2589351. Based on observation, interview and record review, the facility failed to ensure the resident's incontinence brief preference was honored for one resident (R11) of three residents reviewed for choices.

Inspectors wroteBased on interview, and record review, the facility failed to ensure timely delivery of the Medicare Notice of Non-Coverage (NOMNC-document that tells a resident and/or their representative that Medicare will no longer pay for their stay or services) for one resident (R55) of three residents reviewed for Medicare coverage and liability.

Inspectors wroteBased on interview and record review, the facility failed to ensure a 14 day stop date for a PRN (as needed) anti-psychotic medication for one (R7) of five residents reviewed for unnecessary medications. On 08/04/25 at 9:28 AM, R7 was observed in bed. They did not respond to verbal greetings or open their eyes. During subsequent observations the resident was primarily non-responsive and non-communicative. Review of the facility record for R7 revealed they were originally admitted into the facility on [DATE] and had current diagnoses that included Cerebral Infarction with Left Hemiplegia, Vascular Dementia, and Anxiety Disorder. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5/15 indicating severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure incontinence care was provided timely for one resident (R34) and bedding was changed timely for one resident (R46) of three reviewed for activities of daily living.

Inspectors wroteThis citation pertains to intake 2580294. Based on interview, and record review, the facility failed to ensure Heparin (blood thinner) was administered per physician order, hospital discharge orders were accurately transcribed, and vital signs completed for three residents (R14, R17, and R55) out of five residents reviewed for following physician orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident inhalers were dated when opened in one of four medication carts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) and failed to ensure nursing staff used appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteThis citation pertains to Intakes MI00150910 and MI00150259. Based on interview and record review, the facility failed to prevent staff to resident verbal abuse for one sampled resident (R906) from a total of four residents reviewed for abuse resulting in feelings of being disrespected.

Inspectors wroteThis citation pertains to Intake MI00150377. Based on interview and record review, the facility failed to monitor, timely initiate and complete treatment orders for a new wound, for one sampled resident (R902) of four reviewed for wounds, resulting in the potential for wound deterioration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfortable room temperatures, for two resident rooms (#118 and #206), resulting in resident complaints of cold rooms.

Inspectors wroteThis citation pertains to MI00146809. Based on interview and record review, the facility failed to provide a bed hold policy notification for three residents (R902, R904, R905) out of three residents reviewed for hospitalizations.

Inspectors wroteThis citation pertains to Intake MI00146837. Based on observation, interview and record review, the facility failed to notify the physician of vital signs and medication refusals for one resident (R904) of seven residents reviewed for care standards.

Inspectors wroteThis citation pertains to Intake MI00145446. Based on interview and record review, the facility failed to protect one (R4) of three residents reviewed for abuse, from sexual abuse (grabbing their breast) by another resident (R45) .

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain carpet throughout the facility in a clean, sanitary, and safe condition affecting all 58 residents residing at the facility.

Inspectors wroteBased on interview and record review the facility failed to employ a full-time activities director this deficient practice has the potiential to affect all 58 residents that resident in the facility. Findings Include: On 7/15/2024 at 2:00 PM, an interview was conducted with a resident regarding activities in the facility. The resident stated the facility does not have an Activities Director and has not had one in months. The resident confirmed they do not have many activities, including none on the weekend. On 7/16/2024 at 10:00 AM, an interview was conducted with the Regional Nursing Home Administrator (RNHA). The RNHA stated they do not believe the facility has an Activities Director right now, but they have hired one and they should be starting soon. On 7/16/2024 at 11:29 AM, an interview was conducted with Activities Aide (AA) I. [...]

Inspectors wroteThis citation pertains to Intake MI00145043 Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, resulting in the potential for inadequate coordination of care and negative clinical outcomes, potentially affecting all residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to record and post necessary staffing information to ensure the facility had adequate staff per regulatory guidance to meet the care needs of the residents. This deficient practice had the potential to affect all 58 facility residents.

Inspectors wroteThis citation pertains to intakes MI 143412 Based on observation, interview, and record review, the facility failed to ensure meal portion sizes met the nutritional needs of the residents, resulting in the potential for inadequate protein intake, weight loss, and decreased meal enjoyment. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteThis citation pertains to Intake MI00145270. Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for one resident (R2) and seven confidential group residents, resulting in dissatisfaction during meals.

Inspectors wroteThis citation pertains to intake MI 143412 Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner and in accordance with the scheduled mealtimes for the resident, resulting in late meals and resident dissatisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare and serve food under sanitary conditions. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to effectively administer its daily operational processes to provide for the needs of residents for all 58 residents residing in the facility by not correcting unsafe carpet throughout the hallways of the facility, and maintaining or timely replacing resident care equipment.

Inspectors wroteThis citation has multiple deficient practice statements. Deficient practice #1. Based on interview and record review, the facility failed to implement an active water management plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the 58 residents in the facility.

Inspectors wroteThis citation pertains to Intake: MI00143142. Based on observation, interview, and record review, the facility failed to answer call lights timely for four residents (R50, R49, R24, and R9) out of five reviewed for call lights. Findings Include: R50 On 7/15/2024 at 9:03 AM, R50's call light was observed activated. A computer screen behind the nurse's station showed that R50's light had been activated for 13:00 minutes. At 9:06 AM, R50's light was observed activated. Two certified nurses' assistants were noted to walk past R50's room and a nurse was noted at their cart down the hallway. At 9:10 AM, R50's light was observed still activated. At 9:12 AM, a nurse was observed going into R50's room and deactivating the call light. R50 was heard stating they wanted a pain pill. On 7/15/2024 at 2:33 PM, R50 was interviewed regarding call light waits. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities to meet the resident needs for four residents (R9, R19, R20, and R32) out of five reviewed for activitites.

Inspectors wroteBased on interview and record review, the facility failed to provide a 14 day stop date to an antianxiety or provide adequate documentation to justify use beyond 14 days for PRN (as needed) medication for two residents (R21 and R44) out of four reviewed for unnecessary medications. Findings Include: R21 A review of the medical record revealed that R21 admitted into the facility on 6/26/2024 with the following diagnoses, Anxiety and Rheumatoid Arthritis. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R21 also required assistance with bed mobility and transfers. Further review of the physician orders revealed the following orders, Alprazolam-Schedule IV tablet;0.25 mg: amt: 1 tablet; oral. Special Instructions: take 1 tablet 2 times a day as needed. Alprazolam-Schedule IV tablet;0.5 mg: amt: 1 tablet; [...]

Inspectors wroteThis citation pertains to Intake MI00145142. Based on observation, interview, and record review, the facility failed to ensure patient equipment was in safe operating condition for the prevention of hazards and accidents for four residents (R49, R2, R34 and R6) from a sample of five residents.

Inspectors wroteThis citation pertains to Intake MI00145142. Based on interview and record review, the facility failed to ensure that a (name of) total assistance mechanical lift was available for two residents (R2 and R9 ) of two residents reviewed for accommodation of needs/choices, resulting in residents not being able to get in and out of bed safely and as desired.

Inspectors wroteThis citation pertains to Intake MI00145446. Based on interview and record review, the facility failed to ensure abuse allegations were reported timely to the State Agency (SA) for one resident (R4) of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide written transfer notification to the resident and Ombudsman notification for one Resident (R29) of two residents reviewed for required acute care hospital transfer notifications.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a plan of care for one resident (R15) out of three residents reviewed for respiratory care.

Inspectors wroteBased on interview and record review, the facility failed to update the fall care plan interventions following resident falls for one resident (R39) of two reviewed for care planning.

Inspectors wroteThis citation pertains to Intake MI00145293. Based on interview and record review, the facility failed to provide consistent, scheduled showers for one resident (R29) of three residents reviewed for Activities of Daily Living (ADL) bathing care needs.

Inspectors wroteThis citation has two Deficient Practice Statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to set up follow up appointments for one resident (R55) out of two residents reviewed for follow up appointments, resulting in delay of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative services to one resident (R29) of one resident reviewed for limited range of motion and restorative services.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a physician responded to Pharmacist Medication Regimen Reviews (MRR) recommendations timely for one resident (R29) out of two reviewed for MRR's.

Inspectors wroteThis citation pertains to Intake Number MI00141707. Based on observation, interview and record review, the facility failed to provide wound care treatment and prevention interventions as ordered for one resident (R706) of three residents reviewed.

Inspectors wroteThis citation pertains to Intake Numbers M100141492, M100142045 and M100142910. Based on interview and record review, the facility failed to provide pain medication as ordered for one resident (R703) of three residents reviewed.

Inspectors wroteBased on observation, interview, and observation, the facility failed to assess for self-medication administration prior to leaving inhalers in room, for one resident (R708) out of two reviewed for self-medication administration, resulting in medications left in the resident's room and the potential for error in administration. Findings Include: On 10/9/2023 at 9:11 AM, R708 was observed in their room and laying in bed. R708 was observed with three inhalers at their bedside. R708 stated that they always keep their inhalers at the bedside and use them when they feel like they need them. R708 stated that they don't use them on a schedule, just when they feel like they need to use them. A review of the medical record revealed that R708 admitted into the facility on 5/13/2023 with the following diagnoses, Displaced Fracture and Bipolar Disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 1:1 feeding assistance to two residents (R703 and R704) out of four reviewed for dining, resulting in the potential for inadequate meal intake and potential for aspiration.