Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeside Health Center during CMS and state inspections, most recent first.
Two residents with PTSD did not have care plans that addressed their PTSD, including the cause and triggers they may exhibit. One resident had moderate cognitive impairment and was independent with ADLs, and the other had COPD and bipolar disorder. The SSD acknowledged the findings.
Missing Documentation of Change in Condition for Resident Treated for URI: A resident with severe cognitive impairment and ADL assistance needs was placed on Amoxicillin for URI, but the chart did not document the change in condition that led to treatment. Progress notes and vital signs did not show URI signs or symptoms, although later NP documentation noted increased nasal drainage, cough, nasal congestion, no fevers, and a history of recurrent sinus infections.
The facility failed to report resident-to-resident abuse incidents to the State Agency within the required timeframe. In one case, a cognitively intact resident was involved in an altercation with another resident with dementia, and the report was delayed by over 5 hours. In another case, an incident between two residents was reported 18 hours later. The SSD was unaware of the specific reporting timeframe, while the DON confirmed it should be within 2 hours.
The facility failed to have a licensed Nursing Home Administrator overseeing daily operations. The Assistant Administrator, who lacks a license, was present during the survey, while the Interim Administrator, licensed since November 2023, was on vacation and only visits 2-3 days a week. The Regional President, also licensed, visits weekly, but the facility lacks consistent oversight.
A resident with severe cognitive impairment and a history of aggressive behavior was not adequately supervised, leading to repeated incidents of physical abuse towards another resident. Despite being care planned for aggressive behaviors, the facility failed to implement effective supervision measures, resulting in physical assaults. Interviews with staff revealed awareness of the resident's declining state and increased aggression, but the lack of consistent one-on-one supervision contributed to the abuse.
A facility failed to report and investigate a bruise on a resident's arm, despite the resident's claim of being punched. Staff were unaware of the injury, and no investigation was initiated until a surveyor intervened. Another resident reported being hit in the nose, but the incident report inaccurately stated no injuries occurred, despite evidence of a laceration. The facility's documentation contained inconsistencies, highlighting a failure to adhere to policies on reporting and investigating abuse.
The facility failed to follow physician orders for medication administration for three residents. One resident's insulin was held without orders, and clonidine was not given for high blood pressure. Another resident received Diltiazem HCl despite low blood pressure readings, and a third resident was given Amlodipine Besylate despite low blood pressure and heart rate readings. The DON and RN Unit Manager acknowledged these discrepancies.
A resident with dementia and anxiety was observed in pain, making loud verbal whines and groaning, but staff did not respond promptly. Despite the care plan's instructions to monitor and address pain, there was no documentation of pain medication being administered on the day of observation. Staff interviews revealed awareness of the resident's pain indicators but inconsistent communication and documentation.
The facility failed to ensure proper consultant pharmacy services, resulting in medication management issues for several residents. A psychotropic medication was used beyond the recommended duration without reevaluation, and insulin and clonidine were not administered according to physician parameters. Additionally, medications were given outside specified blood pressure and heart rate parameters for two residents, with staff acknowledging these discrepancies.
A facility failed to ensure a PRN order for lorazepam, a psychotropic medication, was limited to 14 days or extended with a documented duration for a resident with anxiety disorder. The order lacked an end date, and the facility's policy did not require specifying a duration, leading to non-compliance with regulatory standards. The consultant pharmacist agreed that the medication should have a specific duration.
The facility failed to maintain accurate clinical records for two residents, resulting in discrepancies in psychotropic medication documentation and delayed implementation of contact precautions. One resident's medication doses were inconsistent between physician notes and active orders, while another resident's contact precautions were ordered two days after a positive C. difficile result. The DON and Infection Preventionist acknowledged these issues during reviews.
Failure to Address PTSD in Care Plans
Penalty
Summary
Provide care or services that was trauma informed and/or culturally competent was not implemented for two residents with a diagnosis of PTSD. Record review showed Resident #4 was admitted with diagnoses including PTSD, and a comprehensive assessment documented moderate cognitive impairment, independence with activities of daily living, and PTSD as the primary medical condition. The resident’s care plan did not address PTSD, including the cause and triggers the resident may exhibit. Record review also showed Resident #91 was admitted with diagnoses including COPD, bipolar disorder, and PTSD. The resident’s care plan likewise did not address PTSD, including the cause and triggers the resident may exhibit. In both cases, the Social Service Director acknowledged the findings during interview.
Missing Documentation of Change in Condition for Resident Treated for URI
Penalty
Summary
The facility failed to document a change in condition for a resident who was being treated for an upper respiratory infection. The resident had severe cognitive impairment and required partial to moderate assistance with activities of daily living. The facility’s policy required documentation of an acute change in status, including assessment findings, vital signs, oxygen saturation, nursing interventions, and communication with the healthcare team, but the resident’s record did not show signs or symptoms of an URI in progress notes dated 12/05/25 through 12/13/25, and the vital signs review also did not show evidence of infection. The resident’s care plan and physician orders showed antibiotic therapy for URI, including Amoxicillin 500 mg by mouth every 12 hours for 7 days. A progress note dated 12/14/25 documented that the resident was receiving Amoxicillin for URI and tolerating it well, but the record did not contain documentation of the change in condition that led to the antibiotic treatment. The DON acknowledged the missing documentation during interview, and a later interview indicated the resident had been seen by the NP for worsening upper respiratory signs and symptoms, including increased nasal drainage, cough, and nasal congestion, with no fevers and a history of recurrent sinus infections.
Delayed Reporting of Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to timely report allegations of resident-to-resident abuse to the State Agency for four of six sampled residents. In the first incident, Resident #1, who was cognitively intact with a BIMS score of 14, was involved in an altercation with Resident #2, who had multiple diagnoses including Moderate Vascular Dementia and was unable to complete a BIMS assessment. The incident occurred at 11:00 AM and was reported to the Abuse Registry at 12:43 PM, but the report to the State Agency was delayed until 4:26 PM, approximately 5 and a half hours after the incident. In the second incident, Resident #5 was involved in an altercation with Resident #6. The incident occurred at 6:00 PM and was reported to the Abuse Registry at 10:39 AM the following day, with the report to the State Agency submitted at 11:49 AM, approximately 18 hours after the incident. During interviews, the Social Services Director (SSD) and the Director of Nursing (DON) acknowledged the reporting delays. The SSD was unaware of the specific timeframe for reporting to the State Agency, while the DON confirmed that the reporting timeframe for both Adult Protective Services and the State Agency is within 2 hours.
Lack of Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to appoint a licensed Nursing Home Administrator responsible for the management and daily operation of the facility. Upon entrance, the surveyor was greeted by the Assistant Administrator, who did not possess a Nursing Home Administrator's license and was awaiting to take the test. The current Administrator was on vacation and communicated with the facility via emails and phone calls, being physically present only 2-3 days a week. The Administrator has been serving as the Interim Nursing Home Administrator since September 2024 and has been licensed since November 2023. The Regional President, who is also a licensed Nursing Home Administrator, visits the facility weekly. However, the facility lacks a licensed Administrator overseeing daily operations due to the Interim Administrator's limited presence.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident with a known history of aggressive behavior. Resident #2, who had severe cognitive impairment and required substantial assistance with daily activities, was involved in multiple incidents of aggression towards other residents, including Resident #3. Despite being care planned for aggressive behaviors, Resident #2 was not adequately supervised, leading to repeated incidents of physical abuse. Resident #2 was admitted with diagnoses including Dementia and Major Depressive Disorder and had a documented history of physically aggressive behavior. The facility's records show that Resident #2 entered Resident #3's room naked and physically assaulted her, causing bruising to her lip. In another incident, Resident #2 was found in a striking position over his roommate. Despite these incidents, the facility did not implement effective supervision measures to prevent further occurrences. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed that the facility was aware of Resident #2's declining cognitive state and increased aggression. Although the facility had discussions with Resident #2's family about the need for one-on-one supervision, the family did not consistently provide this support. The Director of Nursing acknowledged that the lack of supervision contributed to the physical abuse of Resident #3, indicating a failure in the facility's responsibility to protect residents from abuse.
Failure to Report and Investigate Injuries and Abuse
Penalty
Summary
The facility failed to report and investigate an injury of unknown origin for a resident, identified as Resident #36, who was found with a bruise on her right upper arm. Despite the resident's report of being punched by a person in the facility, the bruise was not documented in the skin assessment conducted on the same day. Interviews with staff revealed that they were unaware of the bruise, and no investigation was initiated until the surveyor brought it to the attention of the Social Service Director (SSD) and the Director of Nursing (DON). The resident also reported other instances of abuse, which were not documented or investigated by the facility. Another deficiency was identified in the case of Resident #10, who reported being hit in the nose by a male resident, resulting in a cut. The facility's incident report inaccurately documented that there were no physical injuries, despite a progress note indicating a laceration was treated. The SSD's report contained inconsistencies regarding the resident's actions following the incident, initially stating she went to her room and later that she participated in a social event. The SSD admitted to not being present during the incident and relied on second-hand information, leading to discrepancies in the documentation. These deficiencies highlight the facility's failure to adhere to its policy of reporting and investigating allegations of abuse and injuries of unknown origin. The lack of immediate reporting and thorough investigation of these incidents resulted in inconsistencies and inaccuracies in the documentation, undermining the facility's ability to protect its residents from potential harm.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to ensure nursing staff followed physician orders for medication administration for three residents. For one resident with diabetes, hypertension, and end-stage renal disease, staff held insulin doses on multiple occasions without any physician orders to do so and failed to administer clonidine for high blood pressure as per the physician's parameters. The resident's medical records lacked documentation of any physician notification regarding these actions, and the nurse involved could not provide an explanation other than the resident's frequent refusal of medications, which was also not documented. Another resident with multiple diagnoses, including hypertensive chronic kidney disease and atrial fibrillation, was administered Diltiazem HCl despite having systolic blood pressure readings below the physician-ordered threshold to hold the medication. The medication was given on numerous occasions when the blood pressure was below the specified parameter, indicating a failure to adhere to the physician's orders. A third resident with hypertension and dementia was given Amlodipine Besylate despite having blood pressure and heart rate readings below the parameters set by the physician to hold the medication. The DON and RN Unit Manager acknowledged the discrepancies between the physician orders and the medication administration records, indicating a systemic issue in following medication administration protocols.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident #74, who was observed in pain. On multiple occasions, the resident was heard making loud verbal whines and groaning, indicating discomfort, yet staff did not respond in a timely manner. On one occasion, a Certified Nursing Assistant (CNA) was present in the room but did not attend to the resident's needs, and no other staff intervened. Interviews with staff revealed that they were aware of the resident's pain indicators, such as hitting his leg or crying out, but there was no documentation of pain medication being administered on the day in question. The resident's comprehensive care plan highlighted the risk of generalized pain and discomfort, with specific interventions to observe and report signs of non-verbal pain and to respond immediately to complaints of pain. Despite this, there were no progress notes or medication administration records indicating that pain management was provided on the day the resident was observed in distress. The resident had a history of unspecified dementia, anxiety disorder, and mood disorder, and used an indwelling catheter due to a urinary tract disorder, which required monitoring of pain levels. Staff interviews indicated a lack of consistent communication and documentation regarding the resident's pain management needs.
Consultant Pharmacist Oversight in Medication Management
Penalty
Summary
The facility failed to ensure proper consultant pharmacy services for four of seven residents reviewed for medication use. The consultant pharmacist did not identify a psychotropic medication, lorazepam, used as needed for anxiety in one resident, which was ordered for more than 14 days without a documented end date or specified duration. This oversight was acknowledged by the pharmacist during an interview, who agreed that a re-evaluation should occur for continued use beyond 14 days. Additionally, the consultant pharmacist did not identify issues with insulin and clonidine administration for another resident. Nurses were holding insulin without an order and not administering clonidine as needed for high blood pressure, as per the physician's parameters. The pharmacist admitted to not making any recommendations regarding these medications in the past six months, despite reviewing all medications and parameters. The facility also failed to follow physician orders for blood pressure and heart rate parameters for two other residents. Medications were administered outside the specified parameters, with one resident receiving diltiazem despite low systolic blood pressure and another receiving amlodipine despite low blood pressure and heart rate. The Director of Nursing and other staff acknowledged these discrepancies during interviews, indicating a lack of adherence to physician orders.
Failure to Specify Duration for PRN Psychotropic Medication
Penalty
Summary
The facility failed to comply with regulatory requirements regarding the use of psychotropic medications for a resident. Specifically, the facility did not ensure that a PRN order for lorazepam, a psychotropic medication, was limited to 14 days or extended with a documented duration for use. The policy in place did not include the requirement for indicating a duration for PRN orders, which is necessary for regulatory compliance. This oversight was identified during a review of the facility's policy and the resident's medical records. Resident #22, who was admitted to the facility with an anxiety disorder and was receiving hospice services, had a PRN order for lorazepam initiated without a specified duration. The order allowed for the medication to be administered every four hours as needed for anxiety, but lacked an end date or duration. The consultant pharmacist acknowledged the need for re-evaluation of the medication's use beyond 14 days and confirmed that the order should have included a specific duration. The last recommendation from the pharmacist was to adjust the frequency of the medication from every two hours to every four hours as needed.
Deficiencies in Medication Documentation and Contact Precautions
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in medication documentation and timely implementation of contact precautions. For one resident, there were contradictions in the documented doses of psychotropic medications, including clonazepam, seroquel, and trazodone, between the physician's progress notes and the current active orders. The Director of Nursing acknowledged the inaccuracies in the physician documentation during a review of the resident's records. Additionally, the facility did not promptly implement contact precautions for another resident who tested positive for Clostridium difficile. Although the laboratory results were reviewed by the facility, the order for contact precautions was not written until two days later. The Infection Preventionist admitted to the delay, stating that she conducts audits on Mondays and had not backdated the order, resulting in a lapse in timely precautionary measures.
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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 West Palm Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Skilled Nursing Facility Llc | 1.4 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of West Palm Beach | 1.7 mi | ★★★★★ | 4 | 0 |
| Westgate Health And Rehabilitation Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Lourdes-noreen Mckeen Residence For Geriatric Care | 2 mi | ★★★★★ | 20 | 0 |
| Rehabilitation Center Of The Palm Beaches, The | 2.1 mi | ★★★★★ | 0 | 0 |
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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 July 2026) and official state health department websites.