Lakeside Post Acute

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

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.

Quality of Life and Care Deficiencies

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

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Egress Deficiencies

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

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Egress Deficiencies

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

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

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

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

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

Meet requirements for the installation and maintenance of electrical systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Nutrition and Dietary Deficiencies

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

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Environmental Deficiencies

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

A survey for Incident #2573657 and Incident #2612814 was conducted on 10/14/25 to 12/5/2025. One deficiency was cited.The actual survey exit was 10/14/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/5/25. Based on observations, record review and interviews, the facility failed to ensure one (#3) of four residents were kept free from physical abuse out of six sample residents.Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #4.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 10/9/25 at 10:05 a.m. It read in pertinent part,“Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident’s symptoms.“The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support protecting residents from abuse, neglect, exploitation or misappropriation of property by anyone; developing and implementing policies and protocols to prevent and identify abuse or mistreatment of residents neglect of residents and/or theft, exploitation or misappropriation of resident property; provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior; implementing measures to address factors that may lead to abusive situations; identifying and investigating all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and protecting residents from any further harm during investigations.”II. Incident of physical abuse between Resident #3 and Resident #4 on 6/21/25A. Facility investigationThe facility’s abuse investigation, dated 6/21/25, documented that at approximately 8:15 p.m. Resident #3 and Resident #4 were in the smoking patio area when a ver..

A survey, prompted by Incidents #38947, #39015, #39016, #39108, #39158 and #39211, was completed on 2/10/25 to 2/12/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure that one (#1) of four residents out of eight sample residents received adequate supervision and facility-assisted devices to prevent elopement.Specifically, the facility failed to provide Resident #1 the supervision necessary to prevent elopements. These facility failures created a situation with the likelihood of serious harm to the resident' s health and safety if not immediately corrected.Resident #1 was admitted to the facility on 4/9/24 with a diagnosis of bipolar disorder (major mental illness), adult failure to thrive, cocaine dependence and alcohol dependence. A wander/elopement risk evaluation was completed upon the resident' s admission on 4/9/24 and revealed Resident #1 had no previous elopement attempts and was not at risk for eloping or wandering. However, Resident #1 had an emergency court-appointed guardian who requested the resident not leave the facility without supervision due to her mental illness and substance-seeking behaviors.On 1/10/25 at approximately 10:25 a.m. Resident #1 left the facility unsupervised when the receptionist buzzed someone out the front door and failed to see Resident #1 following behind the other person leaving the facility.After actively searching for the resident and notifying the resident' s guardian about the resident' s elopement, Resident #1 was located by the resident' s guardian at 12:45 p.m. near a homeless shelter approximately five miles from the facility and the facility' s driver picked up the resident and returned her to the facility.-The facility placed Resident #1 on 15-minute checks upon her return to the facility, however, this intervention proved to be ineffective as Resident #1 eloped a second time, four hours after returning to the facility.On 1/10/25 at 5:17 p.m., despite the facility initiating and conducting 15-minute checks on Resident #1, the resident eloped from the facility a second time when a nurse buzzed the resident out the facility door after failing to check the camera to see who was being buzzed out the door. The facilit..

*** CITATION TEXT NOT FOUND *** A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

A survey prompted by #CO37728 and #CO38014 was conducted on 10/21/24. One deficiency was cited. Based on interviews and record review, the facility failed to ensure residents were permitted to remain in the facility and not transfer or discharge for one (#1) of three residents reviewed for discharge planning out of eight sample residents.Specifically, the facility failed to provide Resident #1 with an appropriate discharge process.Findings include:I. Facility policy and procedureThe Transfer or Discharge, Facility-Initiated policy, revised October 2022, was provided by the nursing home administrator (NHA) on 10/21/24 at 1:15 p.m. It read in pertinent part,"If the facility does not permit a resident' s return to the facility (initiates a discharge) based on inability to meet the resident' s needs, the facility will notify the resident, and/or his or her representative in writing of the discharge, including notification of appeal rights."A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident' s discharge or transfer from the facility."Sufficient preparation and orientation for the resident prior to an immediate facility-oriented transfer or discharge includes explaining to the resident where he/she is going and why, and taking steps to minimize his/her anxiety or depression (working with the resident, representative, or family to ensure that the resident' s belongings will be taken care of and transferred to the new location as needed/requested, and ensuring that staff recognize characteristic resident reactions identified during assessment and care planning)."Documentation of Facility-Initiated Transfer or Discharge"When a resident is transferred or discharged from the facility, the following information is documented in the medical record:-The basis for the transfer or discharge; and,-If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include the specific resident needs that cannot be met and the facility' s attempt to meet..