Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeside Special Care Center during CMS and state inspections, most recent first.
A facility failed to ensure a licensed nurse checked meal trays for nine residents during dining, leading to a risk of incorrect diet provision. A staff member served meals without nurse supervision, contrary to facility policy and regulations. Interviews confirmed the nurse's absence and the need for supervision to ensure dietary compliance and resident safety.
The facility failed to comply with food safety standards, as observed during a kitchen inspection. Food items in the reach-in refrigerator were not properly labeled, including a container with an unknown substance and a tub of small containers with creamy substances. Additionally, frozen meats in the walk-in refrigerator were unlabeled. Significant icicle build-up was found in the reach-in freezer, and the temperature log was incomplete. The Director of Dietary Services acknowledged these lapses, which could lead to food-borne illnesses.
Two residents were prescribed antipsychotic medications without appropriate behavior monitoring or approved indications. One resident was given Risperidone for schizoaffective disorder with behavior monitoring based on inappropriate criteria, while another was prescribed Haldol for attempting to kiss staff, which was not considered harmful. The facility's policy requires medications to be clinically indicated and adequately monitored, which was not followed in these cases.
A resident with dysphagia refused a CXR ordered to rule out pneumonia, but the LN failed to document notifying the physician of this refusal. Although the LN claimed to have left a message for the physician, there was no evidence of this in the medical record, as confirmed by the DON.
The facility failed to meet the minimum room size requirement of 80 square feet per resident for 26 out of 27 rooms. Despite rooms being neat and residents not voicing complaints, the survey revealed insufficient space per resident in multiple rooms across different cottages. The deficiency did not adversely affect residents' health or quality of life during the survey.
A CNA at an LTC facility engaged in a consensual sexual act with a resident diagnosed with mental health disorders, despite being trained on abuse prevention. The CNA admitted to developing feelings for the resident and acknowledged the relationship was unprofessional. The facility's policies lacked specific guidance on staff-resident relationships, leading to a deficiency.
A resident with a history of aggressive behavior was downgraded from 1:1 supervision to q15 location monitoring, leading to an incident where the resident hit another resident in the eye, causing a bruise and necessitating a hospital evaluation. Staff confirmed that 1:1 monitoring was effective in preventing aggression, but the downgrade resulted in physical abuse.
A facility failed to develop an individualized care plan for a resident with schizoaffective disorder and impulse behavior, leading to an incident where the resident struck another resident. Despite the effectiveness of 1:1 monitoring, the facility downgraded supervision to every 15-minute safety checks, which was insufficient given the resident's condition.
Failure to Ensure Licensed Nurse Supervision During Meal Service
Penalty
Summary
The facility failed to ensure that a licensed nurse checked the meal trays for nine residents in Cottage Two during a dining observation. On the specified date, a staff member, who was a student waiting to take the exam to become a certified nursing assistant, served meal trays to the residents without the supervision of a licensed nurse. The staff member called out for the licensed nurse to check the trays, but the nurse did not appear, and the staff member proceeded to serve the meals. This lack of supervision put the residents at risk of receiving incorrect diets based on their medical needs. Interviews conducted with the certified nursing assistant, the staff member, and the licensed nurse confirmed that the licensed nurse should have been present to check the meal trays and supervise the dining process to ensure residents' safety. The Director of Nursing acknowledged that the facility's policy required trained personnel to check each food tray for the correct diet before serving, but the policy did not align with the California Code of Regulations, which mandates that licensed nursing personnel ensure residents are served diets as ordered by the attending healthcare practitioner.
Food Safety and Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety standards as observed during a kitchen inspection. During the inspection, it was noted that food items in the reach-in refrigerator were not properly labeled. A transparent container with a green lid contained an unknown white, creamy substance labeled only with the date it was opened, lacking identification of the contents. Additionally, a large plastic tub filled with small containers of a creamy yellow and white substance was found unlabeled and undated. A metal pan in the walk-in refrigerator contained two large frozen meats that were also unlabeled. The Director of Dietary Services (DDS) acknowledged that these items should have been labeled with the food name and preparation date. Further inspection revealed significant icicle build-up in the reach-in freezer, indicating a lack of maintenance. The temperature log, which should have been completed daily, was found to be blank for several days. The facility's policy, titled Food Safety Program, mandates daily temperature checks and proper labeling of all stored food items. The DDS confirmed that these procedures were not followed, which could potentially lead to food-borne illnesses and affect the quality of the food served.
Inappropriate Use of Antipsychotic Medications for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 14 and Resident 21, had an approved indication for the use of antipsychotic medications. Resident 21 was readmitted with a diagnosis of schizoaffective disorder and was prescribed Risperidone. However, the behavior monitoring for this medication was based on inappropriate criteria, such as requesting 'horny pills,' which was not deemed suitable by the Director of Nursing (DON). Interviews with staff revealed inconsistencies in the understanding and monitoring of Resident 21's behavior, with some staff noting agitation and outbursts, while others did not observe the reported behaviors. Resident 14, diagnosed with Parkinsonism and dementia, was prescribed Haldol for sexually inappropriate behavior, specifically attempting to kiss staff. Interviews with staff indicated that Resident 14 exhibited behaviors such as roaming the halls and repetitive talking, but there was no recent evidence of harmful or aggressive behavior. The DON stated that the behavior monitoring for the use of antipsychotic medication should be based on risks for self-harm or harm to others, which was not the case for Resident 14. The facility's policy on psychotropic medication use requires that medications be clinically indicated to treat specific conditions and that there be adequate monitoring for efficacy and adverse consequences. The policy also emphasizes the need for a comprehensive review of the resident's signs and symptoms to identify underlying causes. The failure to adhere to these guidelines resulted in the potential for unnecessary use of psychotropic medications for both residents.
Failure to Document Physician Notification of Resident's Refusal for CXR
Penalty
Summary
The facility failed to ensure the completion of a resident's medical record, specifically for a resident who refused a chest X-ray (CXR). The resident, who was admitted with dysphagia, was ordered a CXR by the physician to rule out pneumonia after a productive cough was documented. However, when the resident refused the CXR, the licensed nurse (LN) did not document that the physician was notified of this refusal. Although the LN stated she left a message for the physician, there was no documented evidence of this communication in the medical record. The Director of Nursing confirmed that the LNs should have documented the resident's refusal in accordance with the facility's policy on charting and documentation.
Room Size Deficiency in Resident Rooms
Penalty
Summary
The facility failed to meet the minimum room size requirement of 80 square feet per resident for 26 out of 27 resident rooms. This deficiency was identified during a survey conducted from February 10 to February 13, 2025. The survey included observations, interviews, and record reviews. Despite the rooms being neat and clutter-free, the facility's Client Accommodation Analysis revealed that the majority of the rooms did not comply with the required space per resident. Specifically, rooms in Cottage 1, Cottage 2, and Cottage 3 were found to have less than the mandated square footage per resident, with some rooms accommodating up to four residents with insufficient space. During the survey, residents were interviewed individually and in groups, and they did not express any complaints regarding privacy, the environment, or their shared rooms. Although the room size variations did not adversely affect the residents' health, safety, quality of care, or quality of life during the survey, the facility's failure to meet the minimum space requirements was noted. The report recommended the continuance of a room size waiver for all affected rooms.
CNA Engages in Inappropriate Relationship with Resident
Penalty
Summary
The facility failed to protect a resident from sexual abuse when a Certified Nursing Assistant (CNA) engaged in a consensual sexual act with the resident. The incident was reported to the California Department of Public Health (CDPH) and investigated on-site. The resident, who was under conservatorship and diagnosed with bipolar disorder, post-traumatic stress disorder, and schizoaffective disorder, was found to have developed a personal relationship with the CNA. The CNA admitted to having feelings for the resident and engaging in a sexual act with him, acknowledging that it was against policy and unprofessional. The CNA had been employed since August 2024 and had received training on abuse prevention and the facility's compliance and ethics program. Despite this, the CNA engaged in unauthorized socializing with the resident, which was against the facility's standards of conduct. The Director of Nursing and the Director of Staff Development both expressed that any sexual relationship between staff and residents is unacceptable and constitutes abuse. The facility's policies did not provide specific guidance on interpersonal relationships between staff and residents, contributing to the deficiency.
Failure to Prevent Physical Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when another resident with a history of hearing voices and responding with physical aggression was removed from 1:1 supervision and placed on q15 location monitoring. This change in supervision was determined to be ineffective in managing the resident's aggressive behavior. As a result, the aggressive resident hit another resident in the eye, causing a bruise and necessitating a hospital evaluation. The aggressive resident had a documented history of schizoaffective disorder and impulse control disorder, with multiple incidents of physical aggression towards peers and staff. Despite the implementation of various approaches, including q15 checks, none were successful in altering the resident's assaultive behavior. The resident was placed on 1:1 monitoring after returning from a psychiatric hospital, which was effective in preventing further incidents. However, the facility later downgraded the supervision to q15 checks, which led to the incident of physical abuse. Interviews with staff, including the Program Counselor, CNAs, and licensed nurses, confirmed that 1:1 monitoring was effective in managing the resident's behavior and preventing physical aggression. The Assistant Director of Nursing and the facility administrator acknowledged that the downgrade to q15 checks was inappropriate and resulted in physical abuse. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse, but this policy was not effectively implemented in this case.
Failure to Develop Individualized Care Plan for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to develop an individualized care plan for a resident diagnosed with schizoaffective disorder and impulse behavior. The resident, who had been readmitted from an acute psychiatric hospital, was initially placed on 1:1 supervision due to internal stimuli with commands to harm others. However, the facility downgraded the supervision to every 15-minute safety checks, despite the resident's history of not self-reporting auditory hallucinations. This change in supervision led to an incident where the resident struck another resident on the side of the face. Interviews with staff, including a CNA, Program Counselor, and Licensed Nurses, revealed that 1:1 monitoring was effective in managing the resident's behavior, as it allowed for immediate intervention when the resident experienced auditory hallucinations. The Assistant Director of Nursing acknowledged that the downgrade in supervision was inappropriate and that the care plan should have been individualized to better address the resident's needs. The facility's policy on resident-to-resident altercations emphasized the importance of an interdisciplinary team assessment and individualized care planning, which was not adequately followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakeside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Royal Home | 2.3 mi | ★★★★★ | 35 | 0 |
| Bradley Court | 2.8 mi | ★★★★★ | 0 | 0 |
| Edgemoor Hospital | 2.9 mi | ★★★★★ | 19 | 1 |
| Stanford Court Skilled Nursing & Rehab Center | 3.2 mi | ★★★★★ | 16 | 0 |
| Country Hills Post Acute | 3.4 mi | ★★★★★ | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.