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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeview Healthcare And Rehab during CMS and state inspections, most recent first.
Failure to Include Residents in Care Plan Conferences: The facility did not document that several residents or their representatives were invited to or attended quarterly care plan conferences tied to MDS assessments. Residents with COPD, Huntington's Disease, Alzheimer's Disease, HF, depression, anxiety, insomnia, and A-fib had overdue care plan meetings, and the Social Services Director confirmed the conferences should have been completed quarterly.
Failure to Provide Written Baseline Care Plan Summaries: The facility did not document providing a written summary of the baseline care plan and order summary to three residents and/or their representatives. The residents had diagnoses including MS, dysphagia, DM, COPD, HTN, schizoaffective disorder, and osteoporosis. The DON confirmed there was no evidence the required summaries were given.
Unsafe food handling occurred during tray line in the main kitchen when an employee picked up tongs from the floor, placed them on another counter, and continued plating food without changing gloves or performing hand hygiene. The Dietary Mgr witnessed the event and confirmed the employee should have washed hands and changed gloves after handling the dropped tongs.
A resident with multiple medical conditions, including a coccyx pressure ulcer, did not have their dignity maintained during a dressing change when an LPN dated the dressing after it was applied, instead of before. The LPN acknowledged this error during an interview.
A resident with encephalopathy, seizures, and pleural effusion had a physician's order for a security bracelet alarm to be worn at all times, and staff documented its use every shift. However, the quarterly MDS assessment was incorrectly coded as not using a wander/elopement alarm, despite daily use being documented and confirmed by the RN Assessment Coordinator.
A resident with COPD, diabetes, and hypertension was observed receiving oxygen at 3.5 lpm, contrary to the physician's order for 1 lpm via nasal cannula PRN. An LPN confirmed the incorrect setting, and the administrator acknowledged the resident's tendency to alter the concentrator without evidence of routine checks to ensure compliance with the prescribed oxygen flow.
An LPN failed to remove gloves and perform hand hygiene during a dressing change for a resident with a coccyx pressure ulcer, proceeding to cleanse the wound without following infection control protocols as required by facility policy. The resident had multiple medical conditions, including a recent fracture, heart failure, dementia, and hypertension.
The facility failed to provide a written summary of the baseline care plan to five residents or their representatives, as required by policy. The clinical records lacked documentation of the summary, which should include goals, medication summaries, dietary instructions, and treatments. This deficiency was confirmed by the Nursing Home Administrator and involved residents with conditions such as high blood pressure, osteoporosis, COPD, dementia, fractures, encephalopathy, seizures, and schizophrenia.
The facility did not ensure that two residents or their representatives were invited to participate in care plan meetings, as required by policy. Despite having quarterly MDS assessments, there was no evidence of invitations or attendance at these meetings, confirmed by staff interviews.
A resident with peripheral vascular disease, heart failure, and hypokalemia experienced a fall resulting in a head laceration requiring sutures. Despite the incident, the facility did not develop a comprehensive care plan to address the fall and injury. The RN Assessment Coordinator confirmed the lack of a care plan, which should have been initiated.
The facility failed to review and revise care plans for two residents as required. One resident, with conditions including high blood pressure and osteoporosis, had 12 care plans with outdated target dates and no evidence of a care plan meeting after a recent MDS assessment. Another resident, with hypertension and anxiety, also lacked evidence of a care plan meeting post-assessment. Interviews confirmed the care plans were not reviewed or revised as required.
A facility failed to ensure accurate physician's orders for a resident who was at risk for elopement and had a wanderguard bracelet applied. Despite the resident's diagnoses of encephalopathy, osteoporosis, and seizures, and an elopement risk evaluation indicating the need for a wanderguard, the clinical record lacked a physician's order for its use. Observations confirmed the bracelet's presence, and the DON acknowledged the absence of the necessary order, highlighting a deficiency in clinical records and nursing services.
The facility failed to maintain proper care of respiratory equipment for two residents with COPD. Both residents had physician orders to change oxygen tubing weekly, but observations revealed that the tubing was not changed as ordered. The DON confirmed these oversights, indicating non-compliance with facility policy and physician orders.
Failure to Include Residents in Care Plan Conferences
Penalty
Summary
The facility failed to ensure that the resident and/or resident representative was offered the opportunity to participate in the development, review, and/or revision of the person-centered care plan for five reviewed residents. Facility policy stated residents and representatives are to be encouraged to participate in assessment and care planning, with advance notice provided for care plan conferences and documentation required if participation was not practicable. The cited deficiency was based on review of clinical records, facility records, and interviews with the residents, representative, and Social Services Director. Resident R5 was admitted with COPD, hyperlipidemia, high blood pressure, and muscle weakness. The record showed a Quarterly MDS with an ARD of 3/25/26, but there was no evidence that the resident or representative was invited to or attended a care plan meeting for that assessment. The resident and representative stated they did not recall being offered the opportunity to participate, and the Social Services Director confirmed the last care plan meeting had been held on 6/02/25 and that the conference was overdue and should be completed quarterly. Resident R7, with Huntington's Disease, anxiety, and insomnia, had Quarterly MDS assessments with ARDs of 11/19/25 and 2/16/26, but the record lacked evidence of invitations or attendance at care plan meetings for those assessments. Resident R25, with Alzheimer's Disease, depression, and high blood pressure, had Quarterly MDS assessments with ARDs of 8/11/25, 12/17/25, 2/1/26, and 4/16/26, and the record lacked evidence of invitations or attendance at care plan meetings for those assessments. Resident R26, with heart failure, depression, and high blood pressure, had Quarterly MDS assessments with ARDs of 10/16/25, 1/7/26, and 4/8/26, and Resident R33, with atrial fibrillation, anxiety, and high blood pressure, had Quarterly MDS assessments with ARDs of 9/30/25, 12/31/25, and 3/26/26; for both residents, the records lacked evidence of invitations or attendance at care plan meetings. For each of these residents, the Social Services Director confirmed the care plan conference was overdue and should be completed quarterly.
Failure to Provide Written Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for three of 13 residents reviewed. Facility policy required that a baseline plan of care be developed within 48 hours of admission and that a written summary be provided to the resident and/or representative, including the resident’s goals and objectives, medication and dietary instructions, services and treatments to be provided, and any updated information from the comprehensive care plan. The medical record review showed no evidence that this written summary was provided for Residents R3, R5, and R6. Resident R3 was admitted with diagnoses including multiple sclerosis, elevated white blood count, dysphagia, and diabetes mellitus. Resident R5 was admitted with diagnoses including COPD, hyperlipidemia, high blood pressure, and muscle weakness. Resident R6 was admitted with diagnoses including schizoaffective disorder, high blood pressure, diabetes mellitus, and osteoporosis. During an interview, the DON confirmed there was no evidence that the written summary of the baseline care plan and order summary had been provided to these residents and/or their representatives.
Unsafe Food Handling During Tray Line
Penalty
Summary
The facility failed to serve food in a safe and sanitary manner during tray line in the main kitchen. A facility policy dated 5/2/25 stated that food and nutrition services employees are to prepare, distribute, and serve food using safe food handling practices, including washing hands before serving food and wearing gloves when handling food directly, with gloves changed between tasks. During observation on 4/29/26 at 11:18 a.m., Employee E1 picked up tongs from the floor, placed the dropped tongs on another counter, and continued to plate food without changing gloves or performing hand hygiene, while the Dietary Manager witnessed the event. During interview at 11:20 a.m., the Dietary Manager confirmed that Employee E1 picked up the tongs from the floor, placed them on another counter, and continued plating food without changing gloves or hand hygiene, and confirmed the employee should have performed hand hygiene and changed gloves after picking up the dropped tongs.
Failure to Maintain Resident Dignity During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to maintain resident dignity during a wound dressing change for a resident with a coccyx pressure ulcer. The LPN was observed placing a new dressing on the resident and then dating the dressing while it was already on the resident, rather than dating it prior to application. During an interview, the LPN confirmed this practice and acknowledged that the dressing should have been dated before being placed on the resident. The resident involved had a history of a fractured right femur, heart failure, dementia, and high blood pressure, and was under physician's orders for specific wound care to the coccyx.
Inaccurate MDS Coding for Wander/Elopement Alarm Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the use of a wander/elopement alarm for one resident. According to the resident's clinical record, there was a physician's order for an alarming security bracelet to be worn at all times, and treatment administration records showed that staff checked the placement of the bracelet every shift throughout the month. However, the quarterly MDS assessment for this resident was coded as 'Not Used' for the wander/elopement alarm, despite clear evidence of daily use. This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator, who acknowledged that the MDS was incorrectly coded and should have indicated daily use of the alarm. The resident involved had diagnoses including encephalopathy, seizures, and pleural effusion, and had been admitted with these conditions. The failure to accurately code the MDS assessment represents a deficiency in ensuring accurate and complete medical records as required by regulation.
Failure to Administer Oxygen Therapy per Physician's Order
Penalty
Summary
The facility failed to provide oxygen therapy according to the physician's order for a resident with chronic obstructive pulmonary disease (COPD), diabetes, and high blood pressure. The physician's order specified oxygen at 1 liter per minute (lpm) via nasal cannula as needed for shortness of breath or comfort. However, observations on two separate occasions revealed the resident was receiving oxygen at 3.5 lpm, which was not in accordance with the order. A Licensed Practical Nurse confirmed that the oxygen concentrator was set at 3.5 lpm, and the Nursing Home Administrator acknowledged that the resident had a habit of changing the concentrator settings. Despite being aware of this behavior, the facility did not provide evidence of implementing routine interventions to ensure the oxygen flow rate was maintained as ordered by the physician.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
A deficiency occurred when an LPN performed a dressing change for a resident with a coccyx pressure ulcer and failed to follow infection prevention and control protocols. The LPN removed the soiled dressing and continued to cleanse the wound without removing gloves or performing hand hygiene, contrary to the facility's policy which requires removal of soiled gloves and handwashing after removing the dressing. This was confirmed during an interview with the LPN, who acknowledged not changing gloves or completing hand hygiene as indicated. The resident involved had a history of fractured right femur, heart failure, dementia, and high blood pressure, and had a physician's order for wound care to the coccyx.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to residents and/or their representatives for five out of thirteen residents reviewed. The facility's policy, dated 5/2/24, mandates that a written summary of the baseline care plan, including goals, objectives, medication summaries, dietary instructions, and any services and treatments, be provided in a language understandable to the resident or their representative. This summary should also be documented in the medical record. However, the clinical records for residents with various medical conditions, such as high blood pressure, osteoporosis, depression, chronic obstructive pulmonary disease, dementia, fractures, encephalopathy, seizures, and schizophrenia, lacked evidence of such documentation. During an interview, the Nursing Home Administrator confirmed the absence of documentation for the provision of the baseline care plan summary to the residents or their representatives. This deficiency was identified for residents with significant medical conditions, including high blood pressure, osteoporosis, chronic obstructive pulmonary disease, dementia, fractures, encephalopathy, seizures, and schizophrenia. The failure to provide and document the baseline care plan summary is a violation of the facility's admissions policy as per 28 Pa. Code 201.24 (e)(4).
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in the development, review, and/or revision of their person-centered care plans. This deficiency was identified for two residents during a review of clinical records and staff interviews. The facility's policy requires a seven-day advance notice of care planning conferences to be provided to residents and their representatives, with records maintained of such notices. However, for two residents, there was no evidence that they or their representatives were invited to or attended care plan meetings in conjunction with their quarterly MDS assessments. Resident R9, who has diagnoses including high blood pressure, osteoporosis, and depression, had a quarterly MDS assessment with an ARD of 5/6/24, but there was no documentation of an invitation to a care plan meeting. Similarly, Resident R16, with diagnoses of hypertension, anxiety, and hyperlipidemia, had a quarterly MDS assessment with an ARD of 5/21/24, and also lacked evidence of being invited to a care plan meeting. The Registered Nurse Assessment Coordinator and the Social Worker confirmed the absence of such documentation during an interview.
Failure to Develop Comprehensive Care Plan for Resident After Fall
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident R12, who was admitted with diagnoses including peripheral vascular disease, heart failure, and hypokalemia. A progress note in the resident's clinical record indicated that the resident was found lying on the floor with a large laceration to the right side of the head, requiring transfer to the emergency room for evaluation and treatment. Upon return from the emergency room with sutures, the resident's clinical record lacked evidence of a care plan addressing the fall and head laceration. The Registered Nurse Assessment Coordinator confirmed the absence of a care plan for the incident, acknowledging that it should have been initiated.
Failure to Review and Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to review and revise care plans for two residents, R9 and R16, as required by their policy. Resident R9, who was admitted with diagnoses including high blood pressure, osteoporosis, and depression, had 12 out of 22 care plans with an outstanding target date of 5/22/24. These care plans covered various problem categories such as impaired vision, respiratory impairment, pain related to osteoporosis, and risk for falls. Despite a Quarterly MDS assessment with an ARD of 5/6/24, there was no evidence of a care plan meeting being held after this date. Interviews with the Registered Nurse Assessment Coordinator and Social Worker confirmed the lack of review and revision of Resident R9's care plans. Similarly, Resident R16, admitted with hypertension, anxiety, and hyperlipidemia, had a care plan for risk for behaviors with a target date of 5/17/24. A Quarterly MDS assessment with an ARD of 5/21/24 was conducted, but the clinical record lacked evidence of a care plan meeting post-assessment. The Registered Nurse Assessment Coordinator confirmed that Resident R16's care plan was not reviewed or revised as required. These deficiencies indicate a failure to adhere to the facility's policy of quarterly care plan reviews and updates.
Deficiency in Physician's Orders for Wanderguard Bracelet
Penalty
Summary
The facility failed to ensure that physician's orders were accurate and reflected the care provided to a resident, identified as Resident R79. The resident's clinical record indicated an admission with diagnoses including encephalopathy, osteoporosis, and seizures. An elopement risk evaluation completed on June 7, 2024, determined that the resident was at risk for elopement, leading to the application of a wanderguard bracelet. However, the clinical record lacked a physician's order for the use of the wanderguard bracelet. Observations on multiple dates confirmed the presence of the wanderguard bracelet on the resident's right wrist. During an interview, the Director of Nursing confirmed the absence of a physician's order for the wanderguard bracelet, which constituted a deficiency in maintaining accurate clinical records and nursing services as per the relevant state codes.
Failure to Maintain Proper Respiratory Equipment Care
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment for two residents, both of whom required respiratory care due to their medical conditions. Resident R6, diagnosed with chronic obstructive pulmonary disease (COPD), high blood pressure, and congestive heart failure, had physician orders to change oxygen tubing every Sunday night shift. However, an observation on June 16, 2024, revealed that the oxygen tubing connected to Resident R6's portable oxygen tank was dated May 20, 2024, indicating it had not been changed weekly as ordered. This was confirmed by the Director of Nursing (DON) during an interview. Similarly, Resident R17, who also had COPD, high blood pressure, and anxiety, had physician orders to change oxygen tubing every Sunday night shift. Observations on June 15 and June 16, 2024, showed that the oxygen tubing was dated June 3, 2024, and had not been changed as per the physician's orders. The DON confirmed this oversight during an interview. These findings indicate a failure to adhere to the facility's policy and physician orders regarding the maintenance of respiratory equipment, as required by 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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What surveyors actually found near you
We read the 28 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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 Smethport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sena Kean Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 11 | 0 |
| Bradford Ecumenical Home, Inc | 14.3 mi | ★★★★★ | 0 | 0 |
| Bradford Manor Nursing And Rehab | 15.3 mi | ★★★★★ | 0 | 0 |
| Pavilion At Brmc, The | 15.3 mi | ★★★★★ | 8 | 0 |
| The Pines Healthcare & Rehab Centers Olean Campus | 18.7 mi | ★★★★★ | 0 | 0 |
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