Lakeshore Post Acute and Rehabilitation Center

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Emergency Preparedness Deficiencies

Establish policies and procedures for medical documentation.

Emergency Preparedness Deficiencies

Establish roles under a Waiver declared by secretary.

Emergency Preparedness Deficiencies

Provide emergency officials' contact information.

Emergency Preparedness Deficiencies

Establish methods for sharing information.

Emergency Preparedness Deficiencies

Establish emergency prep training and testing.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Emergency Preparedness Deficiencies

Establish procedures for tracking staff and patients during an emergency.

Emergency Preparedness Deficiencies

Develop a communication plan.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Egress Deficiencies

Have horizontal exits used in accordance with safety requirements.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

Egress Deficiencies

Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Based on a record review and staff interview it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72. 1. Heat Detection in the kitchen is not shown as being tested NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer’s published instructions. Appliance locations shall be verifie.. Based on documentation and interview, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1. Kitchen Dry Chem system overdue for hydro-testing NFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction at leastevery 6 months. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the affected area of the facility. Deficient items were discussed with the management team at th.. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 7.2.1.4.5.1 1. Delayed egress signage needed for Hallway F & D2. Delayed Egress F hall did not operate for testing, but dropped for with Alarm 7.2.1.6.1 Delayed-Egress Locking Systems.7.2.1.6.1.1(3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:(a)The force shall not be required to exceed 15 lbf (67 N).(b)The force shall not be required to be continuously applied for more than 3 seconds.(c)The initiation of the .. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 101 1. Spare heads dated 75 (Heads need to be sample tested or replaced IAW NFPA 25) 2. Sprinkler Gauge needs to be replaced NFP 255.3.2* Gauges. 5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. NFPA 25 5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the management t.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.90(a).The facility is one story wood framed structure, Type V (000) construction slab on grade without a basement. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1975 and is licensed for 106 beds. This re-certification survey conducted on September 24, 2025 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) chapter 19, Existing Health Care Occupancies. Deficient items were discussed with the ..

A complaint survey, prompted by #CO37646, #CO38984, Incident #37607 and Incident #39106 was conducted on 2/25/25 to 2/26/25. Two deficiencies were cited. Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three (#10, #6, and #4) of three residents reviewed for activities programming out of 22 sample residents.Specifically, the facility failed to offer and provide personalized activity programs for Resident #10, #6 and #4. Findings include:I. Activity calendar The February 2025 activity calendar for the week of 2/23/25 through 2/28/25 revealed there were seven to eight activities scheduled per day. The activity calendar had mind-stimulating activities scheduled on four of seven days for the week (2/23/25, 2/24/25, 2/25/25 and 2/26/25) in the form of Bingo. There was only one activity scheduled for the week for non-social dementia residents in the form of Puppy Friday (2/28/25).II. Resident #10A. Resident statusResident #10, age 78, was admitted on 6/28/22. According to the February 2025 computerized physician orders (CPO), diagnoses included Alzheimer' s disease and dementia. The 2/14/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments. Per staff assessment, the resident had both shor.. Based on record review and interviews the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care for three (#3, #11 and #14) of four residents reviewed for baseline care plans out of 22 sample residents. Specifically, the facility failed to ensure pertinent medical information was included on Resident #3, Resident #11 and Resident #14' s baseline care plans within 48 hours of admission. Findings include:I. Facility policy and procedureThe Comprehensive Person-Centered Care Planning, revised January 2022, was received from the nursing home administrator (NHA) on 2/26/25 at 5:08 p.m. It read in pertinent part, "The interdisciplinary team (IDT) will develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The baseline care plan will include minimum healthcare information necessary to properly care for a resident including, but not limited to: physician orders, dietary orders, social services and PASRR recommendations."II. Resident #3A. Resident statusResident #3, age less than 65, was admitted on 12/27/24. According to the February 20..