Inspection Reports for
Lakeside Post Acute

The complaint investigation substantiated that resident-to-resident physical abuse occurred on 2025-06-21. Resident #3 was the victim and Resident #4 the assailant. The facility conducted interviews, assessments, and implemented monitoring and behavioral interventions. The police were involved and court action was pending.

The facility substantiated that Resident #3 was physically abused by Resident #4 during a verbal altercation that escalated to physical contact, including scratching and a cigarette burn. The facility implemented interventions such as 15-minute checks, behavior monitoring, and care plan updates. Staff interviews and resident statements confirmed the incident and the facility's response.

The complaint investigation found that Resident #1 eloped twice on 1/10/25 due to staff failures in supervision and door monitoring. The resident was found by the guardian and police after each elopement. The facility was cited for past noncompliance with correction dated 1/14/25.

The facility failed to ensure proper supervision of Resident #1, resulting in two elopements on the same day. The facility's interventions, including 15-minute checks, were ineffective, and staff failed to properly monitor the front door, leading to immediate jeopardy to resident health and safety.

The complaint investigation focused on Resident #1 who was discharged AMA after leaving the facility on pass and not returning as agreed. The family was not notified, and the resident did not receive medications upon discharge. The discharge lacked proper physician evaluation and documentation of unmet needs. The discharge was based on a behavioral contract, which the NHA acknowledged was not an acceptable reason for discharge AMA.

The facility failed to provide Resident #1 with an appropriate discharge process, including lack of documentation of resident needs that could not be met, failure to notify the family, and improper handling of medications upon discharge. The discharge was considered Against Medical Advice (AMA) based on a behavioral contract, which is not an acceptable reason for discharge.

The facility had multiple deficiencies including failure to ensure resident privacy, incomplete care plans, medication errors, unsafe smoking practices, improper food storage and sanitation, inadequate infection control practices, and unsafe environmental conditions such as damaged sidewalks and cluttered hallways.

The facility failed to maintain a safe and sanitary environment, including issues with damaged sidewalks, cluttered hallways blocking safety rails, broken handicapped door opener, missing light covers, overgrown landscaping, and accumulation of trash and broken equipment in the parking lot.

The complaint investigation substantiated abuse incidents between residents, failure to provide adequate personal care, medication storage issues, unsanitary food storage, infection control lapses, and vaccination administration failures.

The facility was found to have failed in protecting residents from physical abuse by other residents, failed to provide adequate assistance with personal hygiene for a dependent resident, failed to properly store and label medications and nutritional supplements, failed to maintain sanitary conditions in food storage and preparation areas, failed to maintain infection control practices including cleaning of equipment and lifts, and failed to ensure residents received pneumococcal and influenza vaccinations as per policy.

The facility failed to develop and implement comprehensive care plans for anticoagulant medication use for two residents, failed to prevent a pressure ulcer in one resident by not implementing appropriate interventions, and failed to maintain proper sanitation in the kitchen including cleaning the walk-in cooler, fryer, stove shelf, and properly dating leftovers.