Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Rehabilitation And Care Center during CMS and state inspections, most recent first.
Two residents did not have their comprehensive care plans updated to reflect essential care needs: one with an indwelling urinary catheter and another experiencing severe pain and spasms with movement. Staff interviews and record reviews confirmed that these critical aspects were omitted from the care plans, leaving gaps in guidance for proper care and pain management.
A resident with diabetes was repeatedly administered insulin when blood glucose levels were below the physician-ordered threshold, contrary to the written order to hold insulin if levels were under 150. Multiple instances of this error occurred over several months, with nursing staff unaware of the mistake and the DON not investigating beyond a single incident. No adverse effects were documented in the resident's records.
The facility failed to protect residents from abuse and neglect, with incidents of verbal, physical, and mental abuse reported. A resident's aggressive behavior was not adequately managed, leading to fear among other residents. Additionally, a resident did not receive necessary wound care, and physical abuse incidents involving staff and residents were inadequately addressed.
A LTC facility failed to prevent significant medication errors for four residents. A resident was hospitalized after receiving another's medication due to a nurse's failure to follow the six rights of medication administration. Another resident missed insulin due to a nurse being too busy, while a third received duplicate medication doses due to poor communication between shifts. A fourth resident did not receive insulin due to a shift change miscommunication.
The facility failed to maintain a clean kitchen environment, with inspections revealing condensation icicles falling onto food items and significant ice buildup in the walk-in freezer. Staff interviews highlighted unclear cleaning responsibilities, with the CDM unsure of maintenance schedules and the Maintenance Director emphasizing the need for spot cleaning by kitchen staff.
The facility failed to investigate abuse allegations involving two residents, leading to potential harm. A resident with multiple health issues reported feeling unsafe due to another resident's aggressive behavior, but no documentation was found in the facility's records. Another resident with serious health conditions also reported feeling unsafe, and although a grievance form was provided, the incident was not documented. The facility's leadership was unaware of the situation, indicating a lack of proper investigation.
The facility failed to update care plans for two residents, leading to deficiencies in monitoring and interventions. One resident's care plan lacked documentation for hypo/hypervolemia monitoring despite having renal failure, while another resident's care plan did not include weight management interventions or CPAP machine use, despite physician orders. The DON confirmed these omissions.
A resident with multiple sclerosis, who was cognitively intact, did not receive the scheduled two showers per week as per their care plan. The resident reported only receiving one shower weekly, leading to dissatisfaction with personal hygiene. An LPN confirmed a partial bed bath was given due to staffing shortages, while the DON acknowledged the care plan requirement for two showers weekly.
The facility failed to provide proper foot care for two residents, leading to potential harm. One resident with multiple diagnoses, including muscular dystrophy, had long, thick, and yellowish toenails with a blackened area, but was not referred to a podiatrist as directed. Another resident with diabetes had thick and long toenails, with no documentation of a podiatrist visit or physician notification. Both residents' care plans and physician orders were not followed.
A resident with autism, dementia, and potential schizotypal personality disorder did not receive timely psychiatric evaluation and behavioral services, despite escalating aggressive behavior. The facility's inability to provide necessary evaluations on-site and delay in alternative placement contributed to the deficiency.
An LPN improperly disposed of three pills, including prescription medications metoprolol and gabapentin, in a regular trash can instead of using the facility's Drug Buster Drug Disposal System. This action was against the facility's policy, as confirmed by the DON.
A facility failed to ensure staff wore appropriate PPE for a resident under Enhanced Barrier Precautions (EBP). A CNA was observed emptying a foley catheter drainage bag with only gloves, despite the requirement for both gloves and a gown. The resident had a STOP EBP sign and an isolation cart, and the facility's policy mandates gown and glove use for high-contact care activities. The CNA was re-educated after the incident.
Failure to Include Indwelling Catheter and Pain Management in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in deficiencies related to the omission of critical care needs. For one resident with a diagnosis of benign prostatic hyperplasia and an indwelling urinary catheter, the care plan did not document the presence or care requirements for the catheter. This omission was confirmed through record review and interviews with facility staff, including the Registered Nurse Supervisor, Director of Nursing, and Infection Preventionist, all of whom acknowledged that the catheter should have been included in the care plan to guide staff in providing appropriate care. For another resident with functional quadriplegia, multiple sclerosis, and chronic pain triggered by touch or movement, the care plan failed to address the resident's extreme pain and spasms during repositioning. Although the resident and multiple staff members reported significant pain and frequent refusal of repositioning due to discomfort, the care plan only referenced general skin impairment and pressure ulcer prevention without specific interventions for pain management during movement. The Assistant Director of Nurses attributed the lack of detail to issues with the care plan system following a facility acquisition, and the Director of Nursing confirmed the absence of pain-specific information in the care plan.
Failure to Prevent Significant Medication Errors in Insulin Administration
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and diabetic neuropathy was administered insulin despite blood sugar levels being below the physician-ordered threshold for administration. The physician's order specified that insulin should be held if the capillary blood glucose (CBG) was under 150, and the physician should be notified if CBG was less than 70 or more than 360. However, medication administration records over a three-month period showed multiple instances where insulin was given when the resident's blood sugar was below 150, with values ranging from 86 to 149. The only incident report completed documented one such occurrence, but there was no evidence of adverse effects in the resident's progress notes. Interviews with nursing staff revealed a lack of awareness regarding the medication errors, with one LPN stating she did not realize the errors and an RN attributing the mistake to the way the order was written. The DON was not aware of the repeated errors and had not investigated further incidents beyond the one documented. The facility's medication administration policy required medications to be given according to physician orders as indicated on the electronic medication administration record, which was not followed in these instances.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving verbal, physical, and mental abuse. Several residents experienced verbal abuse from another resident, who exhibited aggressive behavior due to his medical conditions. Despite recommendations for specialist evaluations, the facility did not document any referrals, and the resident continued to pose a threat to others. Interviews with residents revealed a pervasive fear of this resident, indicating a failure to ensure a safe environment. Additionally, the facility did not provide necessary wound care for a resident with a pressure ulcer. The resident was on hospice care, but there was no documentation of wound treatment orders or a care plan. The facility's lack of coordination with the hospice agency resulted in neglect of the resident's medical needs, highlighting a breakdown in communication and responsibility for the resident's care. Physical abuse incidents were also reported, involving staff and resident interactions. A CNA was terminated after physically abusing a resident, and another resident reported being slapped by a fellow resident. These incidents were not adequately addressed, as evidenced by incomplete background checks and insufficient supervision, further demonstrating the facility's failure to protect residents from harm.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting four residents. Resident #129 was mistakenly given a cup of pills intended for another resident, leading to dizziness and hypotension, requiring hospitalization. The error occurred because the float nurse did not adhere to the six rights of medication administration, which include verifying the right medication, dose, dosage form, route, resident, and time. Resident #3 did not receive a scheduled blood sugar check or her prescribed insulin dose due to the day shift nurse being too busy. The nurse failed to ask for assistance and did not complete an incident report, subsequently not returning to work. This oversight resulted in a lapse in the resident's diabetes management, although no immediate harm was reported. Resident #125 received duplicate doses of Norco and Clonazepam due to a lack of communication between the day and evening shift nurses. The travel agency contract nurse administered the second dose without checking the medication administration record (MAR) for the last dose given. Additionally, Resident #127 did not receive his sliding scale insulin due to miscommunication between two nurses during shift change, although no adverse effects were noted.
Deficiency in Kitchen Sanitation and Maintenance
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as observed during inspections. During the initial inspection, condensation icicles from the cooling fans in the walk-in freezer were found falling onto food items such as cardboard boxes of frozen vegetables. Additionally, there was a significant ice buildup around a pipe behind the condenser. A subsequent inspection revealed similar issues, with icicles falling onto both cardboard boxes of vegetables and opened packages of frozen hamburgers. These conditions were in violation of FDA Food Code regulations, which require that food not be stored in direct contact with ice or water if the packaging is susceptible to water entry. Interviews with facility staff revealed a lack of clarity regarding cleaning responsibilities. The Certified Dietary Manager (CDM) indicated that facility maintenance was responsible for cleaning the refrigerators and walk-in freezers, but was unsure when the last inspection of the condenser pipe occurred. The Maintenance Director confirmed that a deep cleaning had been completed over the summer, but emphasized that kitchen staff were responsible for spot cleaning to prevent ice buildup. Despite having a documented cleaning schedule, the CDM could not explain the large ice accumulation, indicating a failure in adhering to the cleaning protocols.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents, which created a potential risk for harm. Resident #4, who has multiple diagnoses including diabetes and chronic hypertensive kidney disease, reported feeling unsafe due to another resident, Resident #61, entering their room and yelling. Despite this incident, there were no reports or documentation found in the facility's grievances, SBARs, or I&A reports for 2024 that addressed this situation. Similarly, Resident #46, with diagnoses including acute and chronic respiratory failure, pulmonary embolism, diabetes, and congestive heart failure, expressed feeling unsafe due to Resident #61's behavior. The resident reported that Resident #61 would wander into their room and yell, causing fear and concern for personal safety. Although a grievance form was provided by an LPN, there was no documentation of the incident in the facility's records. The facility's Administrator and DON were unaware of Resident #61's actions, indicating a lack of proper investigation and documentation of the abuse allegations.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect current needs and interventions, as evidenced by deficiencies found in the care plans of two residents. Resident #4, who was admitted with multiple diagnoses including diabetes and chronic hypertensive kidney disease, had a care plan that directed staff to monitor for signs of hypo/hypervolemia and acute renal failure. However, a review of the MAR/TAR for September through October 2024 showed no documentation of such monitoring. The Director of Nursing (DON) confirmed the absence of blood work tracking and acknowledged that Resident #4's care plan was not updated to reflect these needs. Resident #17, admitted with diagnoses including rib fractures, COPD, and diabetes, expressed a desire to lose weight and had a physician's order for Semiglutide, an anti-diabetic and anti-obesity medication, with weekly weights to be taken. Despite this, the resident's care plan did not include any weight management interventions. Additionally, Resident #17 reported not receiving assistance with a CPAP machine, which was ordered by a physician. The care plan did not reflect the use of the CPAP machine, and the DON confirmed the care plan was not updated to include this intervention.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for a resident who required extensive assistance with personal hygiene and showers. The resident, who was cognitively intact and had multiple sclerosis, was care planned to receive two showers a week. However, the resident reported only receiving one shower per week, specifically on Sundays, and not on Wednesdays as scheduled. The resident expressed dissatisfaction with the lack of showers, noting greasy hair and the need for a shave by the end of the week. The facility's records indicated that the resident received two showers a week, except for one instance of refusal and another when the resident was unavailable. Interviews with the resident and staff revealed discrepancies in the care provided. The resident stated that he did not refuse showers and was not informed of the reasons for missed showers. An LPN confirmed that the resident received a partial bed bath on a Wednesday due to staffing shortages, with only one aide available on the floor that day. The Director of Nursing acknowledged that the resident was supposed to receive two showers a week, as per the care plan. The facility's policy emphasized the importance of meeting personal care needs to promote a healthy environment and prevent infection, yet the care delivery did not align with the resident's care plan.
Failure to Provide Proper Foot Care for Residents
Penalty
Summary
The facility failed to provide appropriate foot care for two residents, leading to potential harm due to lack of proper treatment. Resident #22, who has multiple diagnoses including chronic respiratory failure and muscular dystrophy, was not referred to a podiatrist despite a care plan directive. Observations revealed that Resident #22's toenails were long, thick, and yellowish, with a blackened area on the right big toe. There was no documentation indicating that Resident #22 had been seen by a podiatrist or that the physician was notified about the condition of her toenails. Similarly, Resident #48, who has diagnoses including diabetes and chronic obstructive pulmonary disease, was not referred to a podiatrist as directed by the care plan. Observations showed that Resident #48's toenails were thick and long, and there was no documentation of a podiatrist visit or physician notification regarding the toenail condition. Both residents had care plans and physician orders that were not followed, resulting in a lack of proper foot care and monitoring.
Failure to Provide Timely Psychiatric Care for Resident with Mental Disorders
Penalty
Summary
The facility failed to provide appropriate treatment and behavioral services to a resident with mental disorders, including autism, dementia with agitation, and a potential schizotypal personality disorder. The resident was admitted with a history of aggressive and verbally abusive behaviors, and the care plan included strategies for managing these behaviors. However, despite recommendations for a psychiatric evaluation, the resident did not receive one until several months later, after exhibiting escalating aggressive behavior and being sent to the hospital for lethargy and confusion related to lithium management. The facility's social services noted the resident's behavior was inappropriate and posed a risk to the safety of other residents and staff. Despite recognizing the need for a psychiatric evaluation and alternative placement, the facility was not equipped to provide the necessary evaluations on-site. The resident's behavior continued to escalate, leading to a psychiatric consultation only after the situation had deteriorated significantly. The lack of timely psychiatric intervention and appropriate placement contributed to the deficiency in care for the resident.
Improper Medication Disposal by LPN
Penalty
Summary
The facility failed to ensure proper disposal of medications, as observed during a survey. An LPN was seen disposing of three pills in a regular trash can, which was against the facility's policy for medication disposal. The facility's procedure required medications to be disposed of using the Drug Buster Drug Disposal System. The LPN initially claimed the pills were over-the-counter medications, but later identified them as ASA, metoprolol, and gabapentin, the latter two being prescription medications. The Director of Nursing confirmed that the medications should have been disposed of in the drug buster, not the regular trash can.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for a resident under Enhanced Barrier Precautions (EBP). During an observation, a Certified Nurse Aide (CNA) was seen emptying the urine from a foley catheter drainage bag while only wearing gloves, despite the requirement to wear both gloves and a gown. The resident, who had a STOP EBP sign on their door and an isolation cart outside, confirmed that staff usually wore gowns and gloves when providing care. The resident had a diagnosis of malignant neoplasm of the endometrium and was moderately cognitively impaired. The facility's policy on Enhanced Barrier Precautions, dated April 2024, mandates the use of gowns and gloves for high-contact resident care activities for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. The Infection Preventionist stated that all staff are trained on EBP requirements and that the CNA was re-educated following the incident. However, the CNA's failure to adhere to the EBP protocol during the observed care activity led to the deficiency.
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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 Coeur D'alene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ironwood Rehabilitation And Care Center | 0.7 mi | ★★★★★ | 21 | 0 |
| Coeur D Alene Health Of Cascadia | 0.8 mi | ★★★★★ | 14 | 0 |
| Advanced Health Care Of Coeur D'alene | 1 mi | ★★★★★ | 10 | 0 |
| Life Care Center Of Coeur D'alene | 3.6 mi | ★★★★★ | 25 | 0 |
| Life Care Center Of Post Falls | 5.8 mi | ★★★★★ | 8 | 0 |
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