Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Lakeview Extended Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with Parkinson’s disease and hypertensive heart disease received an incorrect dose of metoprolol succinate sprinkles after the med card was mislabeled as 25 mg while the package contained 100 mg capsules. An LPN questioned the discrepancy and, after speaking with the pharmacist, administered four capsules for a total of 400 mg instead of the ordered 100 mg. The resident was sent to the ER, treated with charcoal, and monitored overnight.
Surveyors found that the medication storage room behind the nurse’s station was left open and unattended, and multiple staff, including CNAs, ES staff, infection control staff, and the DON, acknowledged that the room is sometimes left open during the day despite a written policy requiring medication rooms to be locked at all times. Staff reported that the door is occasionally or frequently left open, sometimes with no nurse present and only a ward clerk or no one at the desk, and an LPN confirmed that the room may be left open when staff are busy and that they have had to close it after finding it unattended.
Indwelling catheter care was not maintained for three residents. A cognitively intact resident had an uncovered urine collection bag with urine visible from the hallway and then upon room entry. Another resident with severe cognitive impairment had catheter tubing wrapped tightly around a leg and hooked under a wheelchair, while a third resident with intact cognition had a catheter bag hanging under the wheelchair and tubing dragging on the floor; staff acknowledged the tubing should be tucked up, and one resident was on antibiotics for a UTI.
The facility failed to maintain a sanitary environment in resident bathrooms and a communal shower room. Observations showed denture cups stored under faucet handles, risking contamination, and improper storage of bedpans and commode buckets. The DON and ICP acknowledged these issues, which violated facility policies on maintaining a safe and sanitary environment.
The facility failed to document physicians' orders for code status in the EMR for three residents, despite having signed forms in paper charts. This oversight was identified during a survey, revealing a lapse in ensuring residents' preferences for life-sustaining treatment were properly recorded and accessible. The DON acknowledged the need for active orders in the EMR, citing issues with medical record number changes as a possible cause.
The facility failed to develop comprehensive care plans for two residents, leading to potential unmet care needs. One resident, with multiple diagnoses including dementia, had no care plan for a hand splint despite frequent refusals to wear it. Another resident, with a history of pneumonia, lacked a care plan for respiratory devices like an incentive spirometer and flutter valve, which were used infrequently.
A resident with moderate cognitive impairment experienced a significant weight loss of 10% over six months, but the facility failed to notify the physician, resulting in a lack of oversight and potential interventions. Despite having a care plan for altered nutrition, there was no documentation of physician notification. The CDM was aware of the weight loss and attributed it to a past acute illness, while the ADON confirmed the need for physician notification. The DON acknowledged the lack of documentation and the limitations of the current communication method.
Medication Dispensing Error With Metoprolol Sprinkles
Penalty
Summary
The facility failed to ensure accurate dispensing of medication for one resident when metoprolol succinate sprinkles were administered in an amount greater than ordered. The resident had diagnoses including Parkinson’s disease and hypertensive heart disease, and the MDS indicated severely impaired cognition with substantial to maximal assistance or dependence for activities of daily living. The active order was for metoprolol succinate ER 100 mg, one capsule by mouth daily for hypertension, replacing a prior 50 mg daily order. The medication error occurred when the resident’s new Kapspargo Sprinkle order arrived with a label that indicated 25 mg, while the packaging contained 100 mg capsules. The nurse questioned the discrepancy and contacted the pharmacist on the unit, who instructed the nurse to give four capsules. Four 100 mg capsules were then administered, resulting in a total dose of 400 mg instead of the ordered 100 mg. The pharmacist later determined that the wrong strength had been selected when the label was created and that the imprint description did not match the medication in the package. After the dose was given, the pharmacist called the facility, but the resident had already been transferred to the emergency room. The DON reported the resident was treated with charcoal, monitored overnight, and returned to the facility the next morning. The DON, pharmacist, and nurse interviews all confirmed that the error stemmed from the mislabeled medication card and the instruction to administer four capsules based on that incorrect label.
Medication Storage Room Not Kept Locked as Required
Penalty
Summary
The deficiency involves the facility’s failure to keep the medication storage room locked and secured as required by policy and professional standards. On the survey date at 8:49 a.m., the medication storage room behind the nurse’s station was observed to be open with no staff present at the nurse’s desk and no staff in sight of the open door. Later that morning, the LPN who closed the door acknowledged that the medication storage room should be closed when no one is around and stated that it gets left open once in a while when staff are busy, and that they have personally observed it open with no one around and then shut it. Multiple staff interviews confirmed that the medication storage room door is at times left open during the day without appropriate monitoring. Two CNAs reported that the room is left open during the day, with one stating that they had seen it open with no one at the desk and that this happens sometimes. Two environmental services staff stated they had seen the door left open, including with no one at the desk or in the room, with one estimating this occurs 3–4 times per week. The infection control staff member reported seeing the door open during the day, including times when no nurses were present and only the ward clerk was there. The DON stated that each nurse has a key, that the room should be locked, and that it should be closed every time nursing staff leave the room. Review of the facility’s “Oral Medication Administration” policy showed that medication rooms on all units are to be kept locked at all times.
Indwelling catheter care not maintained
Penalty
Summary
Appropriate care for residents with indwelling urinary catheters was not provided for three residents reviewed. Resident #19, who was cognitively intact with a BIMS score of 14, was observed on two occasions with a urine collection bag that was not covered, with urine visible from the hallway and then visible upon entering the room. During interview, the infection control nurse stated that urine collection bags should be covered and off the floor. Resident #3, who had severely impaired cognition and diagnoses including diabetes, Parkinson's disease, heart failure, and the need for an indwelling urinary catheter, was observed with a catheter bag covered by a dignity bag resting on a fall mat on the floor, and later with catheter tubing wrapped tightly around the right leg and hooked under the wheelchair. Resident #4, who had intact cognition and diagnoses including suprapubic urinary catheter placement, cerebral palsy, and depression, was observed propelling a wheelchair with the catheter bag hanging under the wheelchair and the catheter tubing dragging on the floor. Nurse B acknowledged the tubing should be tucked up, and the infection control nurse was alerted that Resident #4 was on antibiotics for a UTI and that Resident #3's drainage bag was resting on the floor.
Sanitation and Storage Deficiencies in Resident Bathrooms and Shower Room
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment in the residents' bathrooms and communal shower room, affecting four residents and others using the shower room. Observations revealed that denture cups were improperly stored under the faucet handles in the bathrooms of several residents, creating a potential for contamination during handwashing. Additionally, a bedpan was found stored on top of toilet paper in one resident's bathroom, and another bedpan was stored with personal items under a sink, contrary to proper storage practices. In the communal shower room, several buckets used for commode chairs were found improperly stored. Some buckets were soiled, wet, and not thoroughly cleaned, with one containing a brown substance resembling bowel movement. The Director of Nursing and the Infection Control Preventionist acknowledged these storage issues, indicating that the buckets should be cleaned, dried, and stored properly. The facility's policies on maintaining a safe and sanitary environment were not adhered to, as evidenced by these findings.
Deficiency in Documenting Code Status in EMR
Penalty
Summary
The facility failed to ensure that physicians' orders for code status were present in the electronic medical record (EMR) for three residents, resulting in the potential for the residents' preferences for life-sustaining treatment to not be followed. Resident #19, who is cognitively intact with a BIMS score of 15, had a signed DNR form in the paper chart but no corresponding physician order in the EMR until it was brought to the staff's attention by the surveyor. Similarly, Resident #21, also cognitively intact with a BIMS score of 13, had a signed full code form in the paper chart but lacked a physician's order in the EMR until after the surveyor's intervention. Resident #15, who has diagnoses including non-traumatic brain dysfunction and dementia, was found to have a DNR status in the paper chart without a corresponding physician order in the EMR. The Director of Nursing (DON) acknowledged that there should be an active code status order in the EMR and explained that a change in the medical record number might have caused the order not to carry over. The facility's policy requires that any decision-making regarding a resident's choices be documented in the medical record and communicated to the interdisciplinary team, which was not adhered to in these cases.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, resulting in potential unmet care needs. Resident #6, who was admitted with diagnoses including a right femur fracture, diabetes, polyarthritis, chronic pain, and dementia, had an order for a left hand resting splint to be worn at night. However, the care plan lacked focus on the use of the hand splint and did not address the resident's frequent refusals to wear it. The Assistant Director of Nursing (ADON) acknowledged the absence of a care plan for the hand splint and indicated it should have been included under both the skin integrity and restorative therapy care plans. Resident #25, admitted with diagnoses including pneumonia, anxiety disorder, and stroke, had an incentive spirometer and a flutter valve in their room. Despite the resident's acknowledgment of infrequent use of these devices, there was no care plan in place for their use. The ADON confirmed the absence of a care plan for these respiratory devices, and the Director of Nursing (DON) noted the importance of maintaining healthy lungs for the resident, indicating that a care plan should have been implemented.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of an unintended significant weight loss for a resident, resulting in a lack of physician oversight and potential interventions for weight loss. The resident, who is of advanced age and has moderate cognitive impairment, was readmitted to the facility with diagnoses including atrial fibrillation, nausea/vomiting, generalized weakness, and GERD. The resident experienced a significant weight loss of 10% over six months, dropping from 152.5 lbs to 135.4 lbs. Despite having a care plan for altered nutrition status, the facility did not notify the physician of this weight loss, as indicated by the absence of documentation showing physician notification. Interviews and record reviews revealed that the Certified Dietary Manager (CDM) was aware of the weight loss and attributed it to an acute illness from months prior. The CDM reported that the resident was on nutritional supplements and receiving snacks, with an improving appetite. However, the Assistant Director of Nursing (ADON) confirmed that the physician should have been notified of the weight loss to make necessary orders. The Director of Nursing (DON) acknowledged the lack of documentation for physician notification and stated that nurses should document such notifications in progress notes, as the current method of using tiger text does not retain records.
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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 Harbor Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Courtney Manor | 16.6 mi | ★★★★★ | 10 | 0 |
| Huron County Medical Care Facility | 19.2 mi | ★★★★★ | 0 | 0 |
| Autumnwood Of Deckerville | 22.3 mi | ★★★★★ | 8 | 0 |
| Sanilac Medical Care Facility | 30.3 mi | ★★★★★ | 12 | 0 |
| Medilodge Of Cass City | 31.1 mi | ★★★★★ | 12 | 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.