Lakeview Manor Healthcare Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage of respiratory equipment (BiPAP, nebulizer treatment mask and nasal cannula) for 3 residents (#14, #25, and #27) of 3 residents reviewed for respiratory equipment. Findings Include: Resident #25 On 5/11/26 at 11:37 AM, Resident #25 was observed in their room, sitting in a wheelchair. A nebulizer machine was present on the dresser beside the Resident's bed. The administration set of the nebulizer was connected and uncontained with visible fluid present in the medication chamber. An interview was completed at this time. When queried regarding the nebulizer machine and treatments, Resident #25 stated, Do daily in the morning. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) submission assessment data for one resident (Resident #8) of one resident reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident (Resident #19) of 16 residents reviewed for Activities of Daily Living/ADL care received daily oral care and was shaven as needed. Findings Include:Resident #19: Review of the Face Sheet, care plans dated 4/3/26 through 5/13/26, and nursing notes, dated 4/26 and 5/26, revealed Resident #19 was 62 years-old, alert, admitted to the facility on [DATE], and was totally dependent on staff for all Activities of Daily Living (ADL). The resident's diagnoses included, Cerebral Palsy, other symptoms involving the musculoskeletal system, spastic quadriplegic CP, and required assistance with personal care. Observations made during the survey, revealed Resident #19 had not had any oral care done or had been shaven on the following days and times: Observations made on 5/11/25: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure coordination of care and communication with an external dialysis provider for one resident (Resident #7) of one resident reviewed.

Inspectors wroteBased on interview and record review, 5 of 17 nursing staff (RN's & LPN's) and 5 Nursing Assistants/CNA's of 34 CNA staff failed to have up-to-date annual competency evaluations, resulting in the protentional for Nursing Assistants to not be able to re-certify certification, and improper nursing techniques and care for the facility's census of 54 residents. Findings Include:During an interview done on 5/13/26 at 11:25 a.m., In Service Nurse Director, RN I revealed she had been at the facility for 2 months, and the Nursing Assistant's/CNA's and Nurse's (Rn and LPN) annual competencies (facility competency check-off's) were not up-to-date, no one had done them for months prior to her. In Service Director I stated Before I came, no one did them; the last In Service Nurse did not keep them up-to-date. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a sanitary environment in the kitchen (Soiled equipment, rust on freezer shelves), water in clean and ready for use dishes, and no use-by dates on open and partly used foods, for a census of 57 residents who eat from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely implementation of Transmission Based Precautions (TBP) and ensure appropriate hand hygiene for one resident (Resident #58) of two residents reviewed for Infection Control (IC) resulting in a lack of immediate implementation of TBP for a resident with known positive Clostridioides difficile (C. diff- highly contagious bacterium which effects the colon, can be life threatening, and becomes a spore when outside of the body).

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that weights were done accurately for two residents (Resident #11 & Resident #16).

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1) Ensure proper labeling of open dates and expiration dates of multi-dose medications in 2 of 2 medication carts and 2) Ensure proper labeling of glucose monitor strips for expiration date after opening, resulting in the opened and undated medications and inaccurate blood glucose monitoring.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan related to supplemental oxygen use for one resident (Resident #44) of two residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely update/revise individualized, person-centered care plans to reflect changing care needs for 3 residents (Residents #11, Resident #16 and Resident #111).

Inspectors wroteBased on observation, interview and record review, the facility failed to implement planned interventions for pressure ulcer (wounds caused by pressure) prevention for one resident (Resident #23) of six residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to complete urinary catheter care per professional standards of practice for one resident (Resident #41).

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent including risks and benefits of psychotropic medications were provided for one resident (Resident #44) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Maintain food kitchen equipment in a sanitary and good working condition, and 2) Date prepared foods with made date and use-by date, resulting in an increased likelihood for food borne illness with hospitalization, and cross contamination affecting 57 residents who consumed oral nutrition from the facility kitchen of a total census of 57 residents. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. On 3/25/25 at 9:50 a.m., during the tour of the kitchen accompanied by Dietary Manager G the following concerns were observed: [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer one resident's (Resident #57) morning medications on their scheduled dialysis days, resulting in Resident #57 not being administered approximately 62 doses of scheduled medication on the days that the resident received dialysis. Findings Include: Resident ##57: On 4/2/2024 at 12:47 PM, Resident #57 was observed in his room after finishing lunch. He reported he is currently on restrictions for food and liquids. He has dialysis three times a week on Monday, Wednesday and Friday and the facility transport him to/from about 6:30 AM for his 7:00 AM chair time. [...]

Inspectors wroteBased on record review, the facility failed to provide timely physician's visits for one resident (Resident #15), resulting in a lack of a physician's 60-day follow-up visit, with the likelihood of decreased quality of care and missed assessments of health changes.

Inspectors wroteBased on interview and record review, the facility failed to ensure a that Pharmacy Regimen Review was acted upon for one resident (Resident #15), resulting in a delay of the pharmacy recommendation of a fasting (nothing to eat or drink for 8 to 12 hours beforehand) lab test with the likelihood of unwanted side effects and/or ineffectiveness of the medication going unmonitored.

Inspectors wroteBased on observation, interview, and record review the facility failed to document clinical rationale for the usage of duplicate drug therapy for one resident (Resident #40) of four residents reviewed for unnecessary medications, resulting in Resident #40 being prescribed dual antipsychotic and antidepressant medications in the absence of appropriate documentation that clarified the rationale for and benefits of duplicate therapy. Findings Include: Resident #40: During initial tour on 4/2/2024, Resident #40 was observed ambulating through the hallway and speaking with facility staff. He was not able to be interviewed due to his disease process but appeared to be in good spirits. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to reconcile narcotics during medication/narcotic key exchanges and ensure that narcotic reconciliation was completed accurately for two of two medication carts reviewed, resulting in scribbled over narcotic totals/numbers with the likelihood of narcotic diversion going unnoticed.

Inspectors wroteBased on observation, interview and record review, the facility failed to alert staff and visitors of Enhanced Barrier Precautions in a timely manner and follow Enhanced Barrier Precautions during a medical treatment for one resident (Resident #18), resulting in wound care being completed with no gown and the likelihood of cross contamination and spread of infections causing bacteria.