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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeview Manor Healthcare Center during CMS and state inspections, most recent first.
The facility failed to implement an effective infection control program, with discrepancies in infection tracking and a lack of trend analysis. The IC RN did not conduct specific education based on identified concerns. The beauty parlor was found in unsanitary conditions, with hair and debris in equipment drawers and used curlers and razors with residue. The facility's infection prevention policy was not adhered to, potentially compromising resident safety.
Two residents experienced significant weight loss without timely intervention due to the facility's failure to adhere to its weight management policy. One resident lost 12.7 pounds over 35 days, and another lost 11.5 pounds over 60 days. Despite documented weight changes, care plans were not updated, and necessary re-weighs were not conducted promptly, as confirmed by the Certified Dietary Manager.
The facility failed to properly label open and expiration dates for multi-dose medications and glucose monitor strips. Observations revealed insulin pens, eye drops, and inhalers without expiration dates, and glucose strips with no opening date. This indicates a systemic issue in medication management practices, compromising resident safety.
A facility failed to implement a care plan for a resident receiving supplemental oxygen therapy. The resident, who was severely cognitively impaired, was observed receiving oxygen at 2L/minute via nasal cannula without an active or discontinued care plan for respiratory care. Despite having a health care provider order for oxygen therapy as needed for shortness of breath, the facility did not have a corresponding care plan in place, as confirmed by the Administrator.
The facility failed to update care plans for three residents with changing needs. A resident experienced significant weight loss without care plan adjustments, while another resident's care plan lacked updates despite weight loss. Additionally, a resident with skin impairment had no updated care plan reflecting the condition. Staff interviews revealed confusion over care plan responsibilities, contrary to facility policy requiring interdisciplinary team involvement.
A resident at risk for pressure ulcers was observed with only one heel boot, contrary to their care plan requiring both boots. Staff were unaware of the care plan details, and the second boot was found out of reach on top of an armoire. Interviews revealed confusion among staff about the resident's needs, and the facility administrator could not explain the deficiency.
A resident with an indwelling urinary catheter was observed with the catheter bag improperly positioned, with the spout touching the floor, contrary to the facility's policy. The resident, who was cognitively intact, was unsure of the last catheter change. A nurse acknowledged the improper positioning when pointed out by a surveyor.
The facility failed to maintain kitchen equipment in a sanitary condition and did not properly date prepared foods, increasing the risk of foodborne illness for all 57 residents. Observations included dirty equipment, improperly stored food, and a lack of adherence to food safety policies.
The facility failed to implement timely interventions to prevent the development of a Stage 3 pressure ulcer for one resident and an unstageable pressure ulcer for another. Despite being identified as at risk, the facility did not follow necessary interventions, leading to the worsening of pressure ulcers. Observations revealed missed treatments, lack of proper repositioning, and failure to maintain enhanced barrier precautions.
A resident missed approximately 62 doses of scheduled medication on dialysis days due to the facility's failure to administer medications before or after dialysis. The resident's care plan required medication administration and communication with the dialysis center, but there was no documentation indicating that missed doses were administered upon return or that the physician was informed.
The facility failed to provide timely physician visits for a resident with Chronic Pulmonary Obstructive Disease, Hypertension, and Anxiety. The last documented visit was an 'Acute' visit, and no visits were recorded from that date through the survey exit. This was against the facility's policy requiring physician visits every 60 days.
The facility failed to act on a pharmacy recommendation for a fasting lipid panel for a resident with Chronic Pulmonary Obstructive Disease, Hypertension, and Anxiety. Despite the prescriber's acceptance of the recommendation, the order was not processed, and the lab test conducted did not meet the fasting criteria.
A resident was prescribed dual antipsychotic and antidepressant medications without appropriate documentation of clinical rationale. Despite the resident's aggressive behaviors and efforts to stabilize him on his current medication regimen, the facility failed to provide documented clinical rationale for the duplicate therapy, as required by their policy.
The facility failed to timely alert staff and visitors of Enhanced Barrier Precautions and did not follow these precautions during medical treatment for a resident with a chronic wound. The resident's room lacked necessary isolation caddy and signage, and wound care was performed without a gown, increasing the risk of cross-contamination.
The facility failed to properly reconcile narcotics during key exchanges and ensure accurate documentation for two medication carts. Observations revealed discrepancies and illegible entries in narcotic reconciliation documents, and keys were handed off between staff without proper reconciliation, raising concerns about narcotic security.
Inadequate Infection Control Program and Unsanitary Conditions in Beauty Parlor
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of comprehensive surveillance and analysis of infection data. The Infection Control (IC) Registered Nurse (RN) was unable to provide a consistent and official tracking system for potential infections, relying instead on handwritten notes that were not integrated into the official surveillance system. This led to discrepancies in the reporting of infections, such as the miscount of pneumonia cases, and a lack of identification of potential trends, such as the presence of Klebsiella Oxytoca in urinary tract infections. The IC RN also demonstrated a lack of understanding of process surveillance and had not conducted any specific infection control education based on identified concerns. The facility's beauty parlor was found to be in unsanitary conditions, with excessive hair, dust, and debris in equipment drawers, and used curlers and razors with hair and skin residue. The Director of Maintenance and Housekeeping acknowledged that the housekeeping staff were responsible for cleaning the countertops, sink, and floor, but not the equipment, which was supposed to be cleaned after each use. The Infection Control Nurse expressed disgust at the state of the beauty parlor, indicating a lack of regular oversight and maintenance of hygiene standards in this area. The facility's infection prevention policy outlined the responsibilities of the Infection Preventionist, including the collection and analysis of infection data and trends, and the provision of education and training. However, the facility failed to adhere to these guidelines, as evidenced by the lack of trend analysis, process surveillance, and specific infection control education. This deficiency in the infection control program potentially compromised the health and safety of all 57 residents in the facility.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure accurate weight monitoring for two residents, leading to significant weight loss without timely intervention. Resident #11 experienced a 12.7-pound weight loss over 35 days, equating to a 9.32% loss. Despite the facility's policy requiring re-weighs for significant weight changes, the resident's weight was not rechecked promptly, and the nutritional care plan was not updated to address the continued weight loss. The Certified Dietary Manager (CDM) acknowledged the oversight, noting that significant weight changes should trigger a review by the interdisciplinary team, but this did not occur in a timely manner. Similarly, Resident #16 lost 11.5 pounds over 60 days, a 6.07% decrease, without appropriate adjustments to their care plan. The resident's weight loss was documented, but no new interventions were added to the care plan following the significant weight change. The CDM confirmed that the Registered Dietitian's notes did not lead to any new dietary interventions, indicating a lapse in the facility's response to the resident's nutritional needs. Both cases highlight a failure to adhere to the facility's weight management policy, resulting in unaddressed weight loss for the residents.
Improper Labeling of Medications and Glucose Strips
Penalty
Summary
The facility failed to ensure proper labeling of open dates and expiration dates for multi-dose medications and glucose monitor strips, as observed during a survey. Registered Nurse (RN) D, who was working the medication cart due to a staff nurse call-in, was found to have several insulin pens and bottles without expiration dates, including those for residents using Lantus, Novolog, Humulin, and Aspart insulins. Additionally, a multi-dose bottle of Latanoprost eye drops and Polymyxin/trimethoprim antibiotic were also found without proper labeling. The glucose blood sugar sticks container was opened with missing sticks and no date of opening or expiration noted. Further observations with RN P revealed similar issues with other medications, including Albuterol sulfate nebulizer ampules and various inhalers such as Breyna, Incruse Ellipta, and Trelegy Ellipta, which were opened and used without proper expiration dates. RN P admitted to not dating the inhaler and was unaware of the expiration dates for the medications. The facility's policies on medication administration and disposal were not adhered to, as evidenced by the lack of proper labeling and dating of medications, which is crucial for maintaining their stability and efficacy. The facility's records and policies indicate that certain medications, such as insulin pens and nebulizer solutions, have specific stability periods once opened, which were not followed. The failure to label and date medications properly could lead to the use of expired or ineffective medications, compromising resident safety. The surveyor's findings highlight a systemic issue in the facility's medication management practices, as both RN D and RN P were found to have similar deficiencies in their respective medication carts.
Failure to Implement Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to implement a care plan for a resident receiving supplemental oxygen therapy. The resident, who was observed on two separate occasions receiving oxygen at a rate of 2 liters per minute via nasal cannula, did not have an active or discontinued care plan related to oxygen therapy or respiratory care. The resident was severely cognitively impaired and required supervision to total assistance for various activities of daily living, as noted in the Minimum Data Set (MDS) assessment. Despite having a health care provider order for oxygen therapy as needed for shortness of breath, there was no corresponding care plan in place. During an interview, the facility Administrator confirmed that residents receiving oxygen therapy should have a care plan and acknowledged that the resident in question did not have one. The Administrator reviewed the resident's electronic medical record and confirmed the absence of a care plan related to oxygen therapy, indicating a lapse in the facility's care planning process for this resident's respiratory needs.
Failure to Update Care Plans for Residents with Changing Needs
Penalty
Summary
The facility failed to timely update and revise individualized, person-centered care plans to reflect changing care needs for three residents. Resident #11 experienced a significant weight loss of 12.7 pounds over 35 days, equating to a 9.32% loss, yet the care plan was not updated with new interventions after the weight loss was noted. Similarly, Resident #16 lost 11.5 pounds over 60 days, a 6.07% loss, but the care plan had not been revised with new interventions since a previous revision date, despite the weight loss. Both residents were observed to be thin in appearance, and their care plans did not reflect the necessary adjustments to address their nutritional needs. Resident #111, who had a history of multiple medical conditions including Bipolar Disorder, anemia, and chronic kidney disease, was found to have an actual skin impairment with redness and excoriation in the peri area. However, the care plan only documented a risk for skin impairment without updating it to reflect the actual condition. Interviews with facility staff revealed a lack of clarity and responsibility regarding who should update care plans, with the Director of Nursing indicating that floor nurses were responsible, while the Education Nurse stated that managers usually handled updates. The facility's care planning policy requires that care plans be prepared by the interdisciplinary team based on residents' needs, but this was not adhered to in these cases.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement planned interventions for pressure ulcer prevention for a resident who was at risk for pressure ulcer development. The resident, who was severely cognitively impaired and required maximum assistance for activities of daily living, was observed on multiple occasions with only one heel boot in place, despite the care plan indicating the need for both boots to be worn. The second heel boot was found on top of the resident's armoire, out of reach, and staff were unaware of its location or the requirement for both boots. Interviews with nursing staff revealed a lack of awareness and understanding of the resident's care plan, with one nurse incorrectly believing the resident only needed one boot due to contractures. Another nurse confirmed the resident was supposed to have both boots on but was unable to explain why the second boot was not being used. The facility administrator was unable to provide further explanation regarding the observations and staff interviews, indicating a breakdown in communication and adherence to the resident's care plan.
Improper Urinary Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident, identified as Resident #41, who had an indwelling urinary catheter. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a medical history that included anemia, coronary artery disease, hypertension, neurogenic bladder, diabetes, and depression. During an observation, the state surveyor noted that the urine catheter bag was hanging out of a blue bag with the spout touching the floor, which was visible from the hallway. The resident mentioned that the staff hung it on the side by the door for easier access when emptying. Additionally, the resident was unsure of the last time the catheter was changed. Further observations revealed that the catheter spout was laying on the floor, and approximately 300 ml of clear yellow solution was noted in the catheter bag and tubing. When the surveyor pointed out the improper positioning of the catheter to RN D, the nurse acknowledged that it should not be hanging down out of the bag. The facility's policy on 'Catheter Associated Urinary Tract Infection Prevention' clearly stated that the collection bag and tubing should be kept off the floor, and the drainage spigot should not contact the non-sterile collecting container. These observations and interviews indicate a failure to adhere to the facility's policy and professional standards of practice for catheter care.
Sanitation and Food Dating Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain kitchen equipment in a sanitary and good working condition, as well as to properly date prepared foods with made and use-by dates. During a kitchen tour, several issues were observed, including a food processor with dried food particles near the blade, a clean silver metal pan with dried food particles, and another pan with water inside. Additionally, a coffee pot spigot had a dark sticky substance build-up, and refrigerator fan covers were excessively dusty, blowing directly onto uncovered breadsticks. These observations indicate a lack of adherence to the Public Health Service 2009 Food Code, which requires equipment cleaning at a frequency necessary to prevent recontamination. Furthermore, the facility did not comply with its own Food Purchasing and Storage policy, which mandates that all opened food items be dated with made by, opened, and use-by dates. In the freezer, open and partly used bags of blueberries and rolls were found without use-by dates. An interview with a dietary aide revealed that use-by dates are typically applied to opened items, usually within three days, but this practice was not consistently followed. These deficiencies affected all 57 residents who consumed oral nutrition from the facility's kitchen, increasing the likelihood of foodborne illness and cross-contamination.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement timely interventions to prevent the development of a Stage 3 pressure ulcer for one resident and an unstageable pressure ulcer for another resident. Resident #18, who had diagnoses including diabetes, weakness, and dementia, required extensive assistance with activities of daily living and had severely impaired cognition. Despite being identified as at risk for pressure ulcers, the facility did not follow through with the necessary interventions. Observations revealed that Resident #18's pressure ulcer on the right lateral foot worsened over time, with missed treatments documented in the treatment administration records. Additionally, the resident was often found in the same position for extended periods, indicating a lack of proper repositioning and care. The facility also failed to maintain enhanced barrier precautions as required, with missing isolation caddies and gowns noted during observations. Resident #30, who had diagnoses including acute posthemorrhagic anemia, atrial fibrillation, acute kidney failure, and hemiplegia following a cerebral infarction, developed an unstageable pressure ulcer on the left heel while at the facility. The resident was cognitively intact and able to communicate his needs. Despite this, the facility did not have any interventions in place to prevent the development of the wound while the resident was in bed. The wound was discovered by a CNA during a shower, and subsequent assessments revealed it to be 100% eschar-covered and unstageable. The facility initiated the use of Prafo boots only after the wound was discovered. Interviews with the Director of Nursing and the wound nurse revealed that the facility was aware of the residents' risks for pressure ulcers but failed to implement and follow through with appropriate interventions. The facility's skin management policy, which required ongoing monitoring and evaluation to ensure optimal outcomes, was not adequately followed. This resulted in the development and worsening of pressure ulcers for both residents, highlighting significant lapses in care and documentation.
Failure to Administer Medications on Dialysis Days
Penalty
Summary
The facility failed to administer a resident's morning medications on their scheduled dialysis days, resulting in the resident missing approximately 62 doses of scheduled medication. The resident, who has diagnoses including End Stage Renal Disease, Atrial Fibrillation, Acute Cholecystitis, Heart Failure, and Anxiety, was observed to have missed multiple doses of critical medications such as Midodrine HCL, Apixaban, Metoprolol Tartrate, and others. The resident's care plan required the administration of medications as ordered and communication with the dialysis center, but there was no documentation indicating that missed doses were administered upon the resident's return from dialysis or that the physician was informed of the missed doses. The Medication Administration Record (MAR) for March and April 2024 showed numerous instances where medications were not administered because the resident was at dialysis. Specific medications missed included Midodrine HCL, Renal Oral Capsule, Pantoprazole Sodium, Apixaban, Doxycycline Hydrate, Metoprolol Tartrate, Sennosides, Polyethylene Glycol Powder, Sevelamer HCI, and Ipratropium-Albuterol inhalation solution. Progress notes also indicated multiple instances where medications were not administered due to the resident being on leave of absence (LOA) at dialysis, but there was no follow-up documentation to show that these medications were given later. An interview with Nurse K confirmed that there was no documentation to indicate that the missed medications were administered upon the resident's return from dialysis. The facility's policies on Hemodialysis and Medication Administration did not address the administration of medications on scheduled dialysis days, leading to inconsistencies in medication administration for the resident on dialysis days.
Failure to Provide Timely Physician Visits
Penalty
Summary
The facility failed to provide timely physician visits for Resident #15, who was admitted on 2/26/2016 with diagnoses including Chronic Pulmonary Obstructive Disease, Hypertension, and Anxiety. A record review revealed that the last documented physician visit for the resident was on 1/19/2024, categorized as an 'Acute' visit. There were no documented physician visits from 1/19/2024 through the survey exit on 4/4/2024. According to the facility's policy, each resident must be seen by their physician at least every 30 days for the first 90 days after admission and then every 60 days thereafter. The policy also states that a physician visit is considered timely if it occurs no later than 10 days after the required date. The lack of a physician's 60-day follow-up visit for Resident #15 resulted in a deficiency, indicating a failure to adhere to the facility's policy on timely physician visits.
Failure to Act on Pharmacy Regimen Review
Penalty
Summary
The facility failed to ensure that a Pharmacy Regimen Review was acted upon for a resident, resulting in a delay of the pharmacy recommendation for a fasting lab test. The resident, who had diagnoses including Chronic Pulmonary Obstructive Disease, Hypertension, and Anxiety, was admitted on 2/26/2016. A Medication Regimen Review on 2/5/2024 indicated a need for a fasting lipid panel, which was accepted by the prescriber on 2/6/2024. However, the order was not processed, and subsequent reviews on 3/11/2024 and 4/2/2024 reiterated the unprocessed order. Despite the prescriber's acceptance of the recommendation, the fasting lipid panel was not conducted as required. Instead, a lab test was performed on 3/18/2024 in the afternoon, which did not meet the criteria for a fasting lipid panel. This oversight resulted in the failure to monitor the effectiveness of the resident's medication therapy as recommended by the pharmacy, highlighting a significant lapse in following through with pharmacy recommendations and ensuring proper medical monitoring for the resident.
Lack of Documentation for Duplicate Drug Therapy
Penalty
Summary
The facility failed to document the clinical rationale for the usage of duplicate drug therapy for a resident, resulting in the resident being prescribed dual antipsychotic and antidepressant medications without appropriate documentation. During an initial tour, the resident was observed ambulating and interacting with staff but was unable to be interviewed due to his disease process. A review of the resident's medical records revealed multiple diagnoses, including Alcohol Dependence with Alcohol Induced persisting dementia, Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, Alcoholic Cirrhosis of the liver, and Atrial Fibrillation. The resident was prescribed Mirtazapine and Zoloft for depression and behavior, and Seroquel and Olanzapine for psychosis, without documented clinical rationale for the duplicate therapy. The care plan indicated the resident had potential for mood fluctuations and aggressive behavior, including verbal and physical aggression towards staff. Despite these behaviors, there were no practitioner notes providing a rationale for the duplicate antidepressant and antipsychotic drug usage. An interview with the Social Work Director confirmed the resident's recent aggressive behaviors and the ongoing efforts to stabilize him on his current medication regimen. However, the Social Work Director was unable to locate any documented clinical rationale for the duplicate therapy in the resident's record. The facility's policy on Psychoactive Medication Management requires that physician orders include appropriate clinically supported diagnoses and behavior symptoms, which was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to alert staff and visitors of Enhanced Barrier Precautions in a timely manner and did not follow these precautions during medical treatment for a resident. On 4/02/2024, it was observed that there was no isolation caddy or sign on the door of the resident's room, despite a physician's order for Enhanced Barrier Precautions starting on 03/26/2024. The resident, who had diagnoses including diabetes, weakness, and dementia, required extensive assistance with ADLs and had severely impaired cognition. The care plan indicated the need for Enhanced Barrier Precautions due to a chronic wound, but these precautions were not implemented as required. On 4/03/2024, the resident was observed without a dressing on their right foot, exposing a pressure ulcer. A nurse entered the room to perform wound care without wearing a gown, only gloves, which is against the Enhanced Barrier Precautions protocol. It was not until 4/04/2024 that an isolation caddy with PPE, including gowns, was placed at the doorway. This delay in implementing the required precautions increased the likelihood of cross-contamination and the spread of infection-causing bacteria.
Failure to Properly Reconcile Narcotics and Ensure Accurate Documentation
Penalty
Summary
The facility failed to properly reconcile narcotics during medication/narcotic key exchanges and ensure accurate narcotic reconciliation for two medication carts. The Director of Nursing (DON) explained that narcotics are reconciled when placed in the medication cart and at shift change. However, a review of the narcotic reconciliation documents revealed numerous instances of scribbled over totals and numbers, making it difficult to determine the accurate count of narcotics. Specific dates showed discrepancies and illegible entries, indicating a lack of proper documentation and reconciliation processes. Additionally, during an observation, it was noted that the keys to the medication cart were handed off between staff members without proper narcotic reconciliation. Nurse A did not reconcile the narcotics before or after handing over the keys to the Unit Manager (UM) B and the DON. This lack of reconciliation during key exchanges raises concerns about the security and accountability of the stored narcotics. The facility's policy on controlled substances states that the medication cart and controlled substance drawer should always be locked when not within view of the responsible nurse, but this was not adhered to during the observed key exchanges.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Tawas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Tawas City | 0.2 mi | ★★★★★ | 15 | 0 |
| Iosco County Medical Care Facility | 0.5 mi | ★★★★★ | 30 | 0 |
| Jamieson Nursing Home | 27.7 mi | ★★★★★ | 12 | 0 |
| Medilodge Of Sterling | 27.9 mi | ★★★★★ | 6 | 0 |
| Lincoln Haven Nursing & Rehabilitation Community | 28.8 mi | ★★★★★ | 13 | 0 |
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