Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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.
Improper storage of respiratory equipment was identified for three residents with respiratory needs. Two residents with COPD were observed with nebulizer administration sets connected and uncontained, with visible fluid in the medication chambers, and one resident was heard requesting a nebulizer after staff had already provided a breathing treatment. Another resident with acute respiratory failure, chronic lung disease, and SOB had a BiPAP air piece, nebulizer mask, and NC hooked to an E-tank next to the bed and not stored in a clean bag as required by policy.
A resident with heart failure, dementia, major depressive disorder, and generalized anxiety disorder had MDS data that incorrectly stated the resident was not receiving Hospice, even though the CMS-802, prior MDSs, the EMR care plan, and RN interviews all indicated Hospice services were in place. The MDS RN confirmed the resident was on Hospice and acknowledged the MDS entry was an error.
Failure to provide daily oral care and shaving as needed for a totally dependent resident with CP and spastic quadriplegia. Staff observed the resident awake in bed over multiple shifts without oral care or shaving completed, while the family member said staff usually did it during Sunday shower but had not done so and later said the resident still had not had teeth brushed or been shaven. An RN said there had been no in-service on oral care, a CNA said she sometimes missed it, and the MDS Coordinator confirmed CNAs were still responsible for the task.
Incomplete dialysis communication and coordination of care for a resident receiving HD led to unclear exchange of treatment information between the facility and the dialysis unit. The resident had ESRD, CHF, and other chronic conditions, and the dialysis communication form was left largely blank, including key sections for meds, diet changes, complications, labs, and facility follow-up. Staff were unsure why the resident’s post-treatment weight increased, and the DON later stated the resident received 1.5 L of fluid during dialysis and was discharged after developing fluid overload.
Annual competency check-offs were not current for 5 nurses and 5 CNAs. The In Service Nurse Director said the competencies had not been kept up to date for months before her arrival, and a review of the facility's 2025 through 5/2026 records confirmed the missing evaluations. The facility policy stated annual education includes competency check-offs, and State requirements noted CNAs must have annual skill competency evaluations.
Kitchen sanitation and food storage deficiencies were observed during a walkthrough. Clean cups were stored with water still inside them, several open food items lacked use-by or expiration dates, the pureed machine had water inside with the top on, and the freezer had food debris plus chipped coating and exposed rust. The Dietary Manager acknowledged the issues, and facility policy required leftover foods to be dated and metal shelves to be coated to prevent oxidation.
Delayed Contact Precautions and Poor Hand Hygiene for Resident with C. diff: A resident admitted with a known positive C. diff culture was not placed on contact precautions until several days after admission, and no TBP order was in the EMR. A CNA was observed donning PPE without hand hygiene, entering the room, and then going directly into another resident’s room without cleaning hands after removing PPE. The resident’s family member also entered without hand hygiene and brought personal items into the room after staff allowed it.
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.
Improper Storage of Respiratory Equipment
Penalty
Summary
Proper storage of respiratory equipment was not ensured for residents with orders for nebulizer treatments, BiPAP, and oxygen equipment. Resident #25, who had COPD, a prior stroke with right-sided hemiplegia and hemiparalysis, and aphasia, was observed sitting in a wheelchair with a nebulizer machine on the dresser beside the bed. The nebulizer administration set was connected, uncontained, and had visible fluid in the medication chamber. Resident #27, who had COPD, psychotic disturbance, depression, and anxiety, was also observed with a nebulizer machine on the dresser next to the bed, with the administration set connected, uncontained, and visible fluid present in the medication chamber. Later, Resident #27 was heard yelling that they wanted their nebulizer and stated they used it when needed and it had been taken away; RN O told the resident they could not have it because they had just had it, and LPN G stated they had given the resident a breathing treatment that morning. Resident #14, who was alert and his own person, dependent on staff for ADLs, and extremely short of breath with exertion or excess communication, had diagnoses including acute respiratory failure, panic disorder, anxiety, chronic lung disease, respiratory disorders, shortness of breath, and a history of respiratory infections. The resident had a BiPAP machine with connected air piece, a respiratory nebulizer treatment mask, and a nasal cannula hooked to an E-tank next to the bed. On multiple observations, the BiPAP air piece, nebulizer treatment mask, and nasal cannula hook-up were not in a clean bag. The facility's Use of Oxygen policy stated that the O2 cannula or mask, including treatment masks and BiPAP, when not in use, should be stored in a clean bag.
MDS Hospice Status Incorrectly Documented
Penalty
Summary
The facility failed to ensure the accuracy of MDS submission assessment data for one resident. Resident #8 had diagnoses including heart failure, dementia, major depressive disorder, and generalized anxiety disorder, and the facility’s CMS-802 form indicated the resident was receiving Hospice services. However, the most recent MDS assessment completed on 4/10/26 designated that the resident was not receiving Hospice services, despite prior MDS assessments on 10/27/25 and 1/23/26 both indicating Hospice services. Record review also showed an EMR care plan stating the resident was at risk for decline in condition, pain, depression, weight loss, and other symptoms related to terminal prognosis and that the resident receives Hospice services. RN O stated the resident had been on Hospice since admission in October 2025. MDS RN F, who stated they completed the most recent MDS, confirmed the resident was receiving Hospice services and had not been discharged and readmitted to Hospice, then reviewed the EMR and stated the MDS said no Hospice and should have been on Hospice, acknowledging it was an error.
Failure to Provide Daily Oral Care and Shaving
Penalty
Summary
The facility failed to ensure that Resident #19 received daily oral care and shaving as needed. Resident #19 was 62 years old, alert, admitted to the facility, and totally dependent on staff for all ADLs. His diagnoses included cerebral palsy, other symptoms involving the musculoskeletal system, and spastic quadriplegic CP, and he required assistance with personal care. Review of the care plan and nursing notes showed no documentation that the resident’s family member was providing daily oral care or that staff were checking daily to confirm it was completed. During survey observations, Resident #19 was seen awake in bed multiple times over several days while waiting for meals, and he had not had oral care done or been shaven during those observations. The resident’s family member stated that staff usually shaved him on Sundays during his shower, but that it had not been done that Sunday, and later stated that he still had not been shaven or had his teeth brushed and that she was going to do it herself so it would get done. An in-service RN stated there had been no in-service on oral care since returning three months earlier and that CNAs still had to do shaving and oral care. A CNA stated she sometimes missed oral care and shaving if needed, and the MDS Coordinator stated CNAs still had to perform the task and check whether the family member had provided oral care. The facility routine resident care policy stated daily personal hygiene minimally includes shaving and brushing teeth.
Incomplete dialysis communication and coordination of care
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure coordination of care and communication with an external dialysis provider for a resident receiving hemodialysis. Resident #7 had diagnoses including heart disease, CHF, hepatitis C, and ESRD with dialysis dependence, and the MDS indicated the resident was cognitively intact and required set up to moderate assistance with ADLs. Facility staff used a Hemodialysis Communication Form to exchange information with the dialysis unit, but the form for the resident’s treatment was incomplete, with sections for medications during dialysis, medication changes recommended, diet changes needed, complications during dialysis, pertinent labs, condition of shunt, additional comments, and the facility return section left blank. During review of the dialysis communication form, the resident’s pre-dialysis weight was documented as 55.6 kg and the post-dialysis weight as 57.6 kg, which was inconsistent with prior forms showing weight loss during treatment. RN P stated they were unsure why the resident gained weight during dialysis and suggested the dialysis staff may have entered the weights in the wrong area. RN P also stated the facility did not have a direct phone number to the local dialysis facility and would need to call a central number to try to be connected. The DON reviewed the form and confirmed it was incomplete, stating the lack of communication was not okay and that the issue would need to be addressed with the dialysis provider. Further inquiry revealed the dialysis center had given the resident 1.5 liters of fluid during treatment because the resident’s blood pressure was in the 90s and they did not remove much fluid. The DON later stated the resident was on dietary fluid restrictions at the facility as instructed by the dialysis center and that the fluids received during dialysis sent the resident into fluid overload. The resident was also observed with garbled speech that staff reported had been worsening over the prior couple of weeks. The resident was later discharged from the facility due to fluid overload.
Annual Nursing and CNA Competencies Not Kept Current
Penalty
Summary
Nursing staff and nurse aides did not have up-to-date annual competency evaluations for the facility's census of 54 residents. During an interview, the In Service Nurse Director stated she had been at the facility for 2 months and that the annual competencies for nursing assistants/CNAs and nurses (RNs and LPNs) were not current because no one had completed them for months before her arrival. She stated that before she came, no one had done them and that the prior In Service Nurse did not keep them up to date. A review of the facility's annual competencies for 2025 through 5/2026 found 5 nurses and 5 CNAs who were not up to date with their facility annual competencies. The facility's Training for the Compliance Program policy dated 11/4/2024 stated that annual education includes facility annual competency check-offs and that the staff development coordinator or designated staff member is responsible for educating staff. The State expenditures #483 for nurse aide training and competency evaluation dated 12/5/2016 stated that CNAs are required to have annual skill competency evaluations.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure a sanitary kitchen environment for a census of 57 residents who eat from the kitchen. During the kitchen walkthrough with the Dietary Manager, surveyors observed 6 clean and ready-for-use plastic cups containing water inside the cups in the dry cup container. In interview, the Dietary Manager acknowledged the cups were dry, but the observation showed water remained inside the cups rather than being fully air dried. Surveyors also observed an open and partly used bag of chips, an open package of hamburger buns, an open half loaf of bread, and a package of hot dog buns without use-by or expiration dates. In interview, staff acknowledged the open items needed dates, and the facility’s Food Purchasing and Storage policy stated leftover foods, including breads, were to be dated. In addition, the pureed machine was observed clean but with water inside and the top on, and the Arctic Air freezer bottom shelf had an excessive amount of food and crumbs, with white paint/coating chipping off and rust exposed on all shelves. The Dietary Manager stated every shift should clean the freezer, and the facility policy stated metal shelves were to be stainless or coated to prevent oxidation.
Delayed Contact Precautions and Poor Hand Hygiene for Resident with C. diff
Penalty
Summary
The facility failed to ensure timely implementation of Transmission Based Precautions for a resident admitted with a known positive C. diff infection and failed to ensure appropriate hand hygiene during care. Resident #58 was admitted with diagnoses including C. diff infection and diabetes mellitus, and the record review and interviews showed the resident was not placed on contact precautions until 5/11/26, despite being admitted on 5/9/26 with a positive C. diff culture. The infection control RN stated the resident was not on TBP when she reviewed the chart and that she placed the resident on precautions right away after identifying the C. diff result. She also confirmed there was no TBP order in the EMR and that the admitting nurse could have implemented TBP. On 5/11/26, a contact isolation sign was observed on the resident’s door. A CNA was observed approaching the room and beginning to don PPE without first performing hand hygiene. The CNA later entered the room wearing a gown and gloves, and the resident’s family member also donned PPE without performing hand hygiene before entering. The family member brought a coat and purse into the room after asking staff if the items could be taken inside, and staff in the room were overheard saying yes. After exiting the resident’s room, the CNA walked directly into another resident’s room without performing hand hygiene first. When questioned, the CNA stated PPE had been removed just inside the door and explained there was no convenient place to wash hands because the sink was far from the door and there was no hand sanitizer dispenser in the room. The CNA then acknowledged hand hygiene should have been performed before entering the other resident’s room and used hand sanitizer, while also stating they did not know whether hand sanitizer was effective against C. diff. The facility policy reviewed stated contact precautions are to be used for residents with C. difficile and that PPE should be donned before entering the room and doffed before exiting.
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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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.
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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 | ★★★★★ | 0 | 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 | ★★★★★ | 0 | 0 |
| Lincoln Haven Nursing & Rehabilitation Community | 28.8 mi | ★★★★★ | 13 | 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 August 2026) and official state health department websites.