Deficiencies (last 4 years)
Deficiencies (over 4 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
414% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was conducted to assess compliance with safety regulations, specifically to ensure that the nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Findings
The facility failed to ensure adequate supervision for one resident during ambulation when the occupational therapist was inattentive due to using her phone, which could place residents at risk of accidents and injuries. The facility's policies prohibit phone use during resident care, and staff have received in-service training on this policy.
Deficiencies (1)
Failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 10, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately notify Resident #1's Responsible Party and practitioners of a significant change in the resident's physical status, specifically refusal to eat or drink leading to serious health complications.
Complaint Details
The complaint investigation found that Resident #1 refused meals and hydration from 4/9/2025 to 4/11/2025 without notification to the responsible party or practitioners. This led to hospitalization with acute encephalopathy, acute renal failure, and profound dehydration. The facility failed to document refusals properly and notify the responsible party or medical practitioners in a timely manner.
Findings
The facility failed to notify the responsible party and practitioners when Resident #1 refused meals and hydration from 4/9/2025 to 4/11/2025, resulting in the resident being sent to the ER with acute encephalopathy, acute renal failure, and profound dehydration. Documentation and communication failures were identified, and the facility was cited for immediate jeopardy which was later removed after corrective actions.
Deficiencies (2)
Failure to immediately notify Resident #1's Responsible Party and practitioners of significant change in physical status related to refusal to eat or drink.
Failure to maintain acceptable parameters of nutritional status and hydration for Resident #1, resulting in acute medical complications.
Report Facts
Date of Immediate Jeopardy identification: May 8, 2025
Date Immediate Jeopardy removed: May 10, 2025
Resident admission date: Apr 9, 2025
Resident weight: 134
Pulse rate readings: Array
Number of residents identified with low or declining intake: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | LVN - Charge Nurse | Responsible for Resident #1's admission assessment and charge nurse on 4/10/2025; failed to notify RP and document refusals. |
| CNA A | Certified Nursing Assistant | Reported Resident #1 refused meals and hydration on 4/10/2025 and informed charge nurse. |
| NP C | Nurse Practitioner | Saw Resident #1 on 4/11/2025 and ordered ER transfer; unaware of meal refusals. |
| NP D | Nurse Practitioner | Saw Resident #1 on 4/10/2025; unaware of meal refusals. |
| DON | Director of Nursing | Oversight role; unaware of refusals and notification failures; involved in corrective actions. |
| ADM | Administrator | Unaware of refusals; responsible for oversight and corrective action implementation. |
| MD | Medical Doctor | Reviewed hospital records; unaware of refusals; emphasized need for timely notification. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Feb 20, 2025
Visit Reason
The inspection was conducted based on complaints regarding resident dignity and food service safety at Lakeshore Village Nursing and Rehabilitation.
Complaint Details
Complaint investigation revealed substantiated issues of verbal abuse and disrespect toward Resident #11 by staff member CNA C. Multiple food safety violations were also substantiated including improper food storage, labeling, temperature control, and staff hygiene practices.
Findings
The facility failed to treat a resident with respect and dignity, as evidenced by inappropriate staff comments. Additionally, multiple food safety violations were found including improper food storage, labeling, temperature control, and staff hygiene practices in the kitchen and nourishment rooms.
Deficiencies (9)
Failed to treat Resident #11 with respect and dignity; staff made inappropriate comments.
Failed to close food product bags in freezer to prevent exposure to air.
Failed to label and date food items in refrigerators and freezers.
Failed to maintain freezer temperatures resulting in thawed and refrozen foods.
Failed to maintain sanitary environment; staff opened food packages with mouth, ate in kitchen, and used gloved hands improperly.
Failed to ensure proper hair restraints were worn in the kitchen.
Failed to reheat and hold food at proper temperatures; chili served at 110°F instead of ≥140°F.
Failed to maintain proper refrigerator temperature and sanitary conditions in nourishment rooms.
Failed to use utensils for serving food; staff used hands and gloves improperly causing cross contamination risk.
Report Facts
Deficiencies cited: 9
Freezer temperature: 41.3
Freezer temperature: 26.3
Chili temperature: 110
Hot dog temperature: 140
Refrigerator temperature: 44
Refrigerator temperature: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Named in verbal abuse and disrespect finding toward Resident #11. | |
| ADM | Administrator | Interviewed regarding staff behavior and facility policies on abuse and communication. |
| [NAME] H | Cook | Observed and interviewed regarding food handling violations including improper glove use, hair restraint, and opening food with mouth. |
| DM | Dietary Manager | Interviewed regarding food safety practices, temperature monitoring, and staff training. |
| DW | Dietary Worker | Observed and interviewed regarding hair restraint use and food handling practices. |
| DA | Dietary Aide | Interviewed regarding training on hair restraints, hand hygiene, and serving food. |
| DON | Director of Nursing | Interviewed regarding kitchen staff practices and infection control concerns. |
| [NAME] I | Interviewed regarding orientation training and food handling practices. | |
| Dietitian | Telephone interview regarding kitchen monitoring and training. |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 20, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident rights, care, food service, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to accommodate resident needs and preferences, failure to provide appropriate assistance with activities of daily living, failure to ensure food service met nutritional needs and preferences, and failure to maintain food safety and sanitation standards in the kitchen and nourishment rooms.
Deficiencies (7)
Failed to treat residents with respect and dignity, including verbal abuse by staff to Resident #11.
Failed to reasonably accommodate the needs and preferences of residents, including call lights not within reach for Residents #112, #72, and #99.
Failed to promote and facilitate resident self-determination through support of resident choice, including denying residents in rooms access to special meals served in the dining room.
Failed to provide care and assistance to perform activities of daily living, including failure to clean Resident #231's glasses leading to potential vision impairment.
Failed to ensure menus met nutritional needs, were prepared in advance, followed, and reviewed by dietitian, including unapproved special incentive meals and improper portion control.
Failed to ensure each resident received food that accommodated allergies, intolerances, and preferences, including incorrect meal substitutions and failure to honor dislikes and alternate meal requests for Residents #9, #11, #43, and #53.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including improper sealing and dating of food, improper freezer temperatures causing thawing and refreezing, unsanitary food handling practices, improper hair restraints, and improper food holding temperatures.
Report Facts
Residents reviewed for dignity: 6
Residents reviewed for resident rights: 8
Residents reviewed for self-determination: 6
Residents reviewed for ADL abilities: 4
Residents reviewed for food preferences: 12
Residents affected by food service deficiencies: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Named in verbal abuse to Resident #11 and call light placement issues. | |
| ADM | Interviewed regarding verbal abuse incident and call light expectations. | |
| LVN A | Interviewed regarding call light placement for Resident #112. | |
| ADON | Interviewed regarding call light use and placement. | |
| CNA D | Interviewed regarding call light placement and cleaning resident glasses. | |
| CNA B | Interviewed regarding call light placement for Resident #112. | |
| DM | Dietary Manager | Interviewed regarding special meals, menu approval, and food service practices. |
| DA | Interviewed regarding tray line duties and food handling training. | |
| OT | Occupational Therapist | Interviewed regarding cleaning of Resident #231's glasses. |
| Cook H | Observed and interviewed regarding food handling and kitchen hygiene. | |
| DW | Observed and interviewed regarding hair restraint use and food handling. | |
| CNA E | Interviewed regarding special meal service and feeding Resident #9. | |
| CNA F | Interviewed regarding special meal confusion among residents. | |
| Dietitian | Interviewed regarding kitchen audits and special meal service. | |
| DON | Director of Nursing | Interviewed regarding food portioning, kitchen hygiene, and meal service. |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 10, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations, specifically ensuring that drugs and biologicals are stored in locked compartments to prevent unauthorized access.
Findings
The facility failed to ensure that medication carts #1 and #2 were locked and secured, leaving them unattended and accessible to residents, staff, and visitors. Interviews with staff confirmed that medication carts should be locked when not in use to prevent potential severe or fatal reactions from unauthorized medication access.
Deficiencies (1)
Medication carts #1 and #2 were left unattended and unlocked, allowing unsupervised access to prescription and over-the-counter medications.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN-A | Stated she forgot to lock medication cart #1 and acknowledged the risk of residents taking unprescribed medications. | |
| LVN-B | Stated medication carts should be locked unless in use and described potential severe allergic reactions including death. | |
| DON | Director of Nursing | Stated expectation that medication carts be locked unless in use and described potential minor to fatal allergic reactions. |
| ADM | Administrator | Stated expectation that medication and treatment carts be locked when not in use and acknowledged potential for minor or severe reactions or medication theft. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 21, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that Resident #2 ejaculated on Resident #1 in the secured unit of the facility, and that the facility failed to properly investigate and report the incident.
Complaint Details
The complaint alleged that Resident #2 pulled out his penis and ejaculated on Resident #1 on the secured unit. The facility staff reported the incident but the administrator erased the report from the system and did not report it to the state agency within the required timeframe. The investigation was delayed and incomplete, placing residents at risk of undetected abuse and psychosocial harm.
Findings
The facility failed to implement and utilize abuse and neglect policies properly, did not report the alleged abuse to state authorities within required timeframes, and did not conduct a thorough investigation. The incident involved a substance found on Resident #1's brief, suspected to be semen, but the facility's investigation concluded it was not abuse due to lack of evidence and clinical findings. The investigation was incomplete and did not follow facility policy or regulatory requirements.
Deficiencies (2)
Failed to implement policies and procedures to prevent abuse, neglect, and theft, including failure to report and investigate allegations of abuse timely and thoroughly.
Failed to immediately report to the State Agency an allegation of abuse within 2 hours as required.
Report Facts
Residents reviewed for abuse policies: 10
BIMS score: 9
Dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Reported the alleged abuse via text message to the administrator and took photos of the substance on Resident #1's brief. | |
| Director of Nursing (DON) | Conducted the investigation but did not follow facility policy or regulatory requirements, struck out the incident report, and did not report the incident to the state agency. | |
| Administrator | Received the allegation via text, did not report to state agency, and decided with corporate personnel that the incident was not reportable. | |
| Certified Nursing Assistant (CNA) | Found the substance on Resident #1's brief and reported it to the LPN. | |
| Registered Nurse (RN) | Interviewed and aware of the incident but not involved in reporting. | |
| SC/CNA | Interviewed about the incident and substance on the brief. |
Inspection Report
Routine
Deficiencies: 1
Date: Jun 29, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service safety standards, specifically focusing on proper storage, preparation, distribution, and serving of food in accordance with professional standards.
Findings
The facility failed to ensure that food service staff, including a dishwasher and a dietary aide, wore required hairnets and beard restraints while preparing and assembling food, which could place residents at risk of foodborne illness due to physical contamination.
Deficiencies (1)
Failure to ensure food service staff wore hairnets and beard restraints when cooking, preparing, or assembling food.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 16, 2024
Visit Reason
The inspection was conducted due to complaints regarding pharmaceutical services, specifically the failure to administer medications on time and improper handling of controlled substances.
Complaint Details
The visit was complaint-related due to allegations of late medication administration and improper handling of controlled substances. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to provide pharmaceutical services that meet residents' needs, including timely medication administration to Resident #2 and failure to follow controlled substances policy regarding a bottle of oxycodone found in Resident #3's possession without an order. These failures posed risks of medication therapy disruption, overdose, and drug diversion.
Deficiencies (2)
Failure to administer medications (dicyclomine, Eliquis, Zoloft, lactulose, levetiracetam, and enalapril maleate) to Resident #2 on time on multiple dates from 05/09/24 to 05/15/24.
Failure to implement controlled substances policy when a bottle of oxycodone was discovered in Resident #3's possession on 01/19/24 without an order in place.
Report Facts
Medication administration delays: 7
Residents reviewed for pharmaceutical services: 7
Residents affected: 2
Residents administered medication by MA B: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Administered medications, discovered oxycodone in Resident #3's possession, and provided statements regarding medication administration and controlled substances handling. |
| MA B | Medication Aide | Administered medications to Resident #2 and other residents, provided statements about medication administration times and documentation. |
| DON | Director of Nursing | Provided statements regarding medication administration policies, handling of controlled substances, and concerns about missing oxycodone pills. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 20, 2024
Visit Reason
The inspection was conducted as a routine annual survey of Lakeshore Village Nursing and Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Immediate Jeopardy
Deficiencies: 27
Date: Dec 16, 2023
Visit Reason
The inspection was conducted due to multiple complaints and concerns regarding the facility's compliance with regulatory requirements, including resident care, medication administration, infection control, and facility management.
Findings
The facility was found to have multiple deficiencies including failure to provide dignified care, inadequate reasonable accommodation, incomplete advanced directives, unsafe environment, failure to honor resident rights, medication errors, failure to monitor laboratory services, inadequate infection control, failure to provide appropriate activities, and failure to maintain proper facility administration and policies. An Immediate Jeopardy was identified related to the care of a resident with a Left Ventricular Assist Device (LVAD) and monitoring of seizure medication lab levels.
Deficiencies (27)
Failure to treat residents with dignity and respect, including failure of staff to knock and introduce themselves before entering a resident's room.
Failure to reasonably accommodate resident needs, such as ensuring call lights are within reach.
Failure to ensure advanced directives were complete and properly documented.
Failure to provide a safe, clean, and comfortable environment, including non-functioning heating units and unsecured TV cable outlets.
Failure to ensure grievances were promptly addressed and resolved.
Failure to complete and transmit discharge MDS assessments timely.
Failure to develop baseline care plans within 48 hours of admission and ensure RN signature.
Failure to develop and implement comprehensive person-centered care plans to meet residents' medical, nursing, mental, and psychosocial needs.
Failure to include anticoagulant medication in care plan and update care plans after hospitalizations or infections.
Failure to provide professional standards of care in medication administration, including hand hygiene and correct medication dosing.
Failure to provide appropriate care and assistance with activities of daily living, including grooming and personal hygiene.
Failure to provide ongoing activities to meet residents' interests and physical, mental, and psychosocial well-being, especially in the secured unit.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in unstageable pressure ulcers.
Failure to ensure a safe environment free from accident hazards and provide adequate supervision to prevent accidents, including failure to provide fall mats and secure smoking areas.
Failure to provide appropriate respiratory care consistent with professional standards, including proper storage and cleaning of equipment, oxygen administration per orders, and cleaning of oxygen concentrators.
Failure to provide pharmaceutical services that assure accurate dispensing and administration of drugs, including controlled substances, and proper documentation.
Failure to provide trauma-informed and culturally competent care, including failure to complete trauma screening upon admission.
Failure to conduct and document a facility-wide assessment to determine necessary resources to care for residents competently, including failure to update assessment for residents with LVAD.
Failure to ensure medication error rates were below 5%, with errors including incorrect medication dosing and failure to administer ordered medications.
Failure to ensure drugs and biologicals were labeled and stored in accordance with professional standards, including securing medication carts and proper storage of medications.
Failure to provide timely, quality laboratory services/tests to meet residents' needs, including failure to obtain routine seizure medication lab levels.
Failure to provide or obtain dental services for residents, including failure to assist residents in obtaining routine and emergency dental services for missing dentures.
Failure to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature, including failure to provide fortified foods as ordered.
Failure to provide special eating equipment and utensils for residents who need them and appropriate assistance, including failure to provide physician-ordered sippy cups.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including failure to date and seal food items, discard expired items, and maintain kitchen cleanliness.
Failure to maintain a quality assessment and assurance committee with required members attending meetings.
Failure to provide and implement an infection prevention and control program, including failure to implement isolation precautions, educate staff on infection control, and ensure proper hand hygiene and PPE use.
Report Facts
Medication error rate: 6.25
Controlled medication count: 79.5
Controlled medication count: 14
Controlled medication count: 81
Weight loss: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA A | Medication Aide | Named in medication administration and hand hygiene deficiencies |
| Laundry Aide F | Laundry Aide | Named in dignity and respect deficiency for entering resident room without knocking or introduction |
| DON | Director of Nursing | Named in multiple findings including infection control, LVAD care, medication administration, and facility assessment |
| ADON | Assistant Director of Nursing | Named in infection control, medication administration, and incontinent care deficiencies |
| Administrator | Facility Administrator | Named in multiple findings including infection control, medication administration, and facility management |
| RN D | Registered Nurse | Named in medication administration and infection control deficiencies |
| CNA PP | Certified Nursing Assistant | Named in incontinent care and infection control deficiencies |
| CNA SSS | Certified Nursing Assistant | Named in incontinent care and infection control deficiencies |
| SLP MMM | Speech Language Pathologist | Named in dental services deficiency |
| DOR | Director of Rehabilitation | Named in dental services deficiency |
| Housekeeper H | Housekeeper | Named in infection control deficiencies |
| Housekeeper K | Housekeeper | Named in infection control deficiencies |
| LVN G | Licensed Vocational Nurse | Named in LVAD care and infection control deficiencies |
| LVN KK | Licensed Vocational Nurse | Named in LVAD care deficiencies |
| LVN CCC | Licensed Vocational Nurse | Named in LVAD care and infection control deficiencies |
| LVN NNN | Licensed Vocational Nurse | Named in LVAD care deficiencies |
| LVN OOO | Licensed Vocational Nurse | Named in LVAD care deficiencies |
| LVN E | Licensed Vocational Nurse | Named in LVAD care and medication administration deficiencies |
| MDS Coordinator L | MDS Coordinator | Named in care planning and medication administration deficiencies |
| MDS Coordinator X | MDS Coordinator | Named in care planning deficiencies |
| Pharmacy Consultant | Pharmacy Consultant | Named in pharmaceutical services deficiencies |
| Medical Director | Medical Director | Named in LVAD care, laboratory services, and infection control deficiencies |
| AD | Activity Director | Named in activities deficiencies |
| RN AAA | Registered Nurse | Named in infection control deficiencies |
| CNA M | Certified Nursing Assistant | Named in infection control deficiencies |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in infection control deficiencies |
| RN B | Registered Nurse | Named in activities deficiencies |
| LVN P | Licensed Vocational Nurse | Named in activities and medication administration deficiencies |
| Dietary Manager | Dietary Manager | Named in dietary services deficiencies |
| CNA R | Certified Nursing Assistant | Named in dietary and infection control deficiencies |
| Housekeeper VVV | Housekeeper | Named in infection control deficiencies |
| LVN CC | Licensed Vocational Nurse | Named in respiratory care and infection control deficiencies |
| CNA O | Certified Nursing Assistant | Named in infection control deficiencies |
| ADON | Assistant Director of Nursing | Named in multiple findings including infection control, medication administration, and incontinent care |
| LVN W | Licensed Vocational Nurse | Named in care planning deficiencies |
| LVN Z | Licensed Vocational Nurse | Named in care planning deficiencies |
| RN DDD | Registered Nurse | Named in laboratory services deficiencies |
| RN EEE | Registered Nurse | Named in laboratory services deficiencies |
| MDS L | MDS Coordinator | Named in laboratory services deficiencies |
| MDS X | MDS Coordinator | Named in laboratory services deficiencies |
| MDS AA | MDS Coordinator | Named in laboratory services deficiencies |
| LVN UUU | Licensed Vocational Nurse | Named in laboratory services deficiencies |
| RN E | Registered Nurse | Named in respiratory care deficiencies |
| LVN KK | Licensed Vocational Nurse | Named in LVAD care deficiencies |
Inspection Report
Deficiencies: 18
Date: Dec 16, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, reasonable accommodation, advanced directives, environment safety, grievance resolution, activities, pressure ulcer care, accident hazards, incontinent care, respiratory care, nursing competencies, pharmaceutical services, medication error rates, drug labeling and storage, facility assessment, and hospice services.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to accommodate resident needs, incomplete advanced directives, unsafe and unclean environment, unresolved grievances, inadequate personal hygiene care, lack of activities especially in secured unit, failure to prevent pressure ulcers, unsafe environment and supervision, improper incontinent care, inconsistent respiratory care, lack of nursing staff competency especially related to LVAD care, inaccurate pharmaceutical services and medication administration documentation, unsafe medication storage and labeling, failure to monitor seizure medication lab levels, incomplete facility assessment for residents with specialized needs, and failure to maintain hospice documentation.
Deficiencies (18)
Failure to treat residents with dignity and respect, including failure of staff to knock and introduce themselves before entering resident rooms.
Failure to reasonably accommodate resident needs, such as ensuring call lights were within reach.
Failure to ensure advanced directives were complete, including missing legal guardian and notary information on DNR forms.
Failure to provide a safe, clean, comfortable, and homelike environment, including broken heating unit and unsecured TV cable outlet.
Failure to ensure prompt efforts to resolve grievances, including failure to complete grievance documentation for resident complaints.
Failure to provide adequate personal hygiene care, including failure to maintain clean and trimmed fingernails for residents.
Failure to provide ongoing activities to meet residents' interests and needs, especially in the secured unit, and failure to post activity calendars.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to monitor skin under immobilizer and prevent pressure ulcers.
Failure to maintain a safe environment and provide adequate supervision to prevent accidents, including failure to provide fall mats, secure smoking area, and secure shower room doors.
Failure to provide appropriate care for residents who are incontinent, including improper glove use and hand hygiene during incontinent care.
Failure to provide safe and appropriate respiratory care, including improper storage and dating of nebulizer tubing, lack of oxygen orders, incorrect oxygen administration, and unclean oxygen concentrators.
Failure to ensure nurses and nurse aides have appropriate competencies to care for residents, including lack of training and education on LVAD care and monitoring.
Failure to provide pharmaceutical services to meet residents' needs, including failure to keep records of controlled medications awaiting disposition, failure to reconcile controlled medications, and failure to document administration of controlled medications.
Failure to ensure medication error rates were below 5%, including administration of incorrect medication doses and failure to administer ordered medications.
Failure to ensure drugs and biologicals were labeled and stored according to professional standards, including unsecured medication carts, mismatched medication labels, and improperly stored nasal spray.
Failure to conduct and document a facility-wide assessment to determine necessary resources to care for residents competently, including failure to update the facility assessment for residents with LVAD.
Failure to arrange for provision of hospice services or coordinate hospice care planning, including failure to maintain hospice binders and ensure communication with hospice providers.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including undated and expired food items, unclean kitchen equipment, improperly worn hairnets, and expired test strips.
Report Facts
Medication error rate: 6.25
Controlled medication count: 79.5
Controlled medication count: 14
Controlled medication count: 81
BIMS score: 10
BIMS score: 1
BIMS score: 15
BIMS score: 15
BIMS score: 12
BIMS score: 15
BIMS score: 9
BIMS score: 15
BIMS score: 7
BIMS score: 14
Blood pressure: 206
Blood pressure: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laundry Aide F | Named in dignity and respect deficiency for failing to knock and introduce herself before entering Resident #34's room | |
| CNA SSS | Named in incontinent care deficiency for improper glove use and hand hygiene with Resident #68 | |
| MA C | Named in pharmaceutical services deficiency for failure to document administration of controlled medication for Resident #52 | |
| MA A | Named in medication error deficiency for incorrect administration of Depakote and Medrol to Resident #16 | |
| RN D | Registered Nurse | Named in respiratory care deficiency for failure to properly administer oxygen to Resident #34 and failure to maintain oxygen concentrator for Resident #93 |
| LVN G | Licensed Vocational Nurse | Named in LVAD competency deficiency for lack of training and improper blood pressure monitoring for Resident #231 |
| LVN KK | Licensed Vocational Nurse | Named in LVAD competency deficiency for lack of training and improper blood pressure monitoring for Resident #231 |
| LVN CCC | Licensed Vocational Nurse | Named in LVAD competency deficiency for lack of training and improper blood pressure monitoring for Resident #231 |
| LVN NNN | Licensed Vocational Nurse | Named in LVAD competency deficiency for lack of training and improper blood pressure monitoring for Resident #231 |
| LVN OOO | Licensed Vocational Nurse | Named in LVAD competency deficiency for lack of training and improper blood pressure monitoring for Resident #231 |
| LVN GGG | Licensed Vocational Nurse | Named in LVAD competency deficiency for lack of training and improper blood pressure monitoring for Resident #231 |
| ADON | Assistant Director of Nursing | Named in multiple deficiencies including dignity and respect, reasonable accommodation, grievance resolution, personal hygiene, incontinent care, respiratory care, pharmaceutical services, medication error, drug labeling and storage, and LVAD competency |
| DON | Director of Nursing | Named in multiple deficiencies including dignity and respect, reasonable accommodation, grievance resolution, personal hygiene, incontinent care, respiratory care, pharmaceutical services, medication error, drug labeling and storage, LVAD competency, facility assessment, and hospice services |
| Administrator | Named in multiple deficiencies including dignity and respect, reasonable accommodation, grievance resolution, personal hygiene, incontinent care, respiratory care, pharmaceutical services, medication error, drug labeling and storage, LVAD competency, facility assessment, and hospice services | |
| Medical Director | Named in LVAD competency and administration deficiencies for failure to monitor lab results and provide oversight | |
| Nurse Practitioner | Named in LVAD competency and administration deficiencies for failure to monitor lab results and provide oversight | |
| Pharmacy Consultant | Named in pharmaceutical services deficiency for failure to ensure proper drug destruction and reconciliation | |
| Dietary Manager | Named in food safety deficiency for failure to ensure food items were dated and kitchen equipment was clean | |
| CNA N | Named in activities deficiency for stating activities were not performed frequently in secured unit | |
| RN B | Registered Nurse | Named in activities deficiency for stating secured unit residents had not received activities for approximately 4 months |
| LVN P | Licensed Vocational Nurse | Named in activities and medication administration deficiencies for lack of activity calendar and missed medication documentation |
| CNA R | Named in fall prevention deficiency for being unaware of fall mat order for Resident #111 | |
| CNA PP | Named in incontinent care deficiency for improper glove use and hand hygiene with Resident #107 | |
| RN AAA | Named in respiratory care deficiency for failure to maintain oxygen concentrator for Resident #93 | |
| CNA O | Named in smoking policy deficiency for emptying ashtrays into plastic trashcan instead of metal container | |
| Director of Clinical Operations | Named in hospice services deficiency for failure to maintain hospice binder | |
| Wound Care NP | Named in pressure ulcer care deficiency for assessment and treatment of pressure ulcers for Resident #54 | |
| Maintenance Supervisor | Named in environment safety deficiency for failure to repair TV cable outlet and shower room door | |
| AD | Named in activities deficiency for staffing shortages and lack of activities in secured unit | |
| Activity Aide | Named in activities deficiency for lack of activities and activity calendar in secured unit | |
| LVN CC | Licensed Vocational Nurse | Named in personal hygiene and incontinent care deficiencies for noting long dirty fingernails and improper care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Lakeshore Village Nursing and Rehabilitation following a survey completed on 08/10/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #1 eloped from the facility and was found deceased approximately 30 feet from the facility. The investigation focused on the facility's failure to provide adequate supervision and devices to prevent accidents.
Complaint Details
The complaint investigation was triggered by Resident #1 eloping from the facility and being found deceased outside. The investigation revealed failures in supervision, risk assessment, care planning, and staff training. Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent accidents for Resident #1, who eloped and was found deceased outside the facility. The facility had not completed appropriate elopement risk assessments or care plan updates after incidents involving the resident. Immediate Jeopardy was identified due to lack of staff training on abuse, neglect, documentation, care plans, and elopement prevention. The facility implemented a plan of removal including staff education, window repairs, elopement risk assessments, and ongoing monitoring.
Deficiencies (1)
Failed to ensure that the resident received adequate supervision and assistive devices to prevent accidents and hazards.
Report Facts
Residents affected: 1
High risk residents for elopement: 19
Screens replaced: 12
Temperature: 99
Temperature: 101
Temperature: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Interviewed regarding Resident #1 incidents, care planning, and staff training |
| ADM | Administrator | Interviewed regarding facility management, education, and plan of removal |
| Maintenance Director | Interviewed regarding window repairs, staff education, and maintenance procedures | |
| SOWK | Social Worker | Interviewed regarding Resident #1 behavior, care planning, and staff education |
| CNA A | Certified Nursing Assistant | Interviewed about Resident #1 observations on day of incident |
| MA A | Medical Assistant | Interviewed about Resident #1 prior incidents and observations |
| Activity Assistant | Interviewed about staff education on abuse, neglect, elopement, and heat exhaustion | |
| LVN A | Licensed Vocational Nurse | Interviewed about staff education and reporting procedures |
| RN | Registered Nurse | Interviewed about staff education and reporting procedures |
| CNA B | Certified Nursing Assistant | Interviewed about Resident #1 behavior and staff response on day of incident |
| Laundry Aide | Interviewed about staff education and facility conditions | |
| CNA C | Certified Nursing Assistant | Interviewed about recent staff education |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 2, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights to dignity and respect, specifically regarding the proper covering of urinary bedside drainage bags for residents requiring such devices.
Findings
The facility failed to ensure that urinary bedside drainage bags for two residents were covered with privacy bags, potentially compromising their dignity. Observations and interviews confirmed that the bags were uncovered and visible from the hallway, and staff acknowledged the requirement to keep these bags covered at all times.
Deficiencies (1)
Failure to ensure Residents #1 and #2's urinary bedside drainage bags were placed in privacy bags, compromising residents' dignity.
Report Facts
Urinary bedside drainage bag volume: 300
Urinary bedside drainage bag volume: 600
Residents reviewed for dignity: 4
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Stated urinary bedside drainage bags are supposed to be covered with a privacy bag at all times and uncovered bags could compromise dignity. |
| CNA B | Certified Nursing Assistant | Stated urinary bedside drainage bags are supposed to be covered at all times and uncovered bags could be embarrassing to residents. |
| RN C | Registered Nurse | Stated residents' bedside drainage bags are supposed to be covered at all times and uncovered bags could risk embarrassment and compromised dignity. |
| CNA D | Certified Nursing Assistant | Stated urinary bedside drainage bags should be covered at all times to prevent compromised dignity and shame. |
| ADM and DON | Administrator and Director of Nursing | Stated urinary bedside drainage bags are supposed to be covered at all times using leaf bags with flaps and uncovered bags could risk embarrassment and compromised dignity. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 2, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Lakeshore Village Nursing and Rehabilitation, summarizing the results of the facility's annual inspection survey completed on 11/02/2022.
Findings
No health deficiencies were found during the inspection. The level of harm and residents affected are both listed as unknown.
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