Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeview Health Center during CMS and state inspections, most recent first.
Verbal and Physical Abuse During Resident Care: Staff used profanity and threatening language toward a resident with dementia during bathing and reportedly sprayed the resident with the shower head after the resident became resistive. In a separate incident, a CNA allegedly cursed at a severely cognitively impaired resident, handled the resident roughly during bed care and a lift transfer, and swatted the resident's hand. Both residents had care plans calling for calm, direct, individualized approaches during care.
A CNA witnessed another CNA make an inappropriate statement to a resident during bathing care and spray the resident with the shower head after the resident became combative and resistive. The witness knew the abuse reporting policy but did not report the incident immediately, and the DON confirmed the allegation was not timely reported to facility management/administration as required.
Staff in the Garden Terrace kitchenette were observed not wearing hair nets or beard restraints while preparing and serving food, contrary to FDA Food Code 2022 and facility policy. The Dietary Manager confirmed that all staff are expected to wear these restraints, and the CNA involved admitted to forgetting the requirements.
The facility failed to ensure a sanitary environment, with staff neglecting to sanitize reusable mechanical lifts between residents, improper glove use during medication administration, and failure to sanitize a common area table after blood glucose checks.
The facility failed to ensure the privacy and confidentiality of resident medical records during medication administration. Staff were observed leaving the MAR open with resident information visible when leaving the medication cart unattended. Interviews confirmed that staff were aware of the policy but sometimes forgot to close the MAR due to being in a hurry. The DON acknowledged the issue and stated that re-education of staff would be conducted.
Verbal and Physical Abuse During Resident Care
Penalty
Summary
The facility failed to ensure residents were free from verbal and physical abuse from staff for two sampled residents, both of whom had care plans and assessments indicating significant cognitive impairment and behavioral symptoms during care. The report cites a facility policy stating that residents will be free from abuse, neglect, and harm and that abuse can include verbal and physical abuse. Despite that policy, staff interactions with residents were described as inappropriate, unprofessional, and rough during hands-on care. For one resident with dementia with behavioral disturbance and alcohol-related dementia, the quarterly MDS showed physical behavioral symptoms and extensive dependence on staff for ADLs. The care plan directed staff to use a calm approach because the resident may make threats, strike out, push, or grab during care. During a bath, two CNAs were assisting the resident when one CNA reportedly told the resident, "if you don't stop, I am going to give you a cold shot," and then sprayed the resident's legs with the shower head. A second staff member reported that the comment and action were inappropriate and that the resident was resistive and combative during the bath. The CNA involved acknowledged the incident, stated the resident was physically aggressive, and admitted it was possible water may have contacted the resident's face while the shower head was moved over the shoulder. For another resident with severe cognitive impairment, the care plan stated the resident could become verbally agitated and physically aggressive when uncertain and instructed staff not to argue or engage in power struggles, to use simple direct language, and not to reorient because it increased agitation. During care, staff alleged that a CNA cursed in the resident's presence, told the resident, "I am not dealing with your shit tonight," grabbed the resident by the ankles and threw the legs back onto the bed multiple times, roughly rolled the resident onto her side to place a sling, and swatted the resident's hand during a lift transfer. A coworker reported the force used could have caused injury. The CNA denied rough handling but admitted using profanity and repositioning the resident's legs back onto the bed. The facility investigation documented these allegations and interviews confirmed the reported verbal abuse and rough handling during resident care.
Failure to Timely Report Alleged Abuse During Bathing Care
Penalty
Summary
The facility failed to ensure that an allegation involving possible abuse was reported within the required timeframe to facility management and other officials. A CNA was aware of an incident involving a resident and another CNA during bathing care, but the incident was not reported immediately or within 2 hours as required when abuse is alleged. The facility policy titled, Resident Protection: Abuse, Neglect, Mistreatment and Misappropriation of Resident Property; Injuries of Unknown Source, required staff who become aware of abuse, mistreatment, neglect, exploitation, or misappropriation to immediately report it to the administrator or designee, and required abuse allegations to be reported within 2 hours when abuse or serious bodily injury is involved. The resident involved had diagnoses including dementia with behavioral disturbance and alcohol related dementia, and the care plan noted the resident may make threats, strike out, push, or grab and required staff to use a calm approach during care. During the incident, two CNAs were assisting the resident with a bath when the resident became combative and resistive to care. One CNA reported hearing the other CNA tell the resident, "if you don't stop, I am going to give you a cold shot," and then spray the resident's legs with the shower head. The CNA who witnessed the event acknowledged knowing the abuse reporting policy but did not report the incident immediately, stating she reported it to the DON the following day instead. The DON confirmed the report was not made timely to facility management/administration.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, staff were observed not wearing hair nets or covering facial hair while preparing and serving food in the Garden Terrace kitchenette. This was observed on multiple occasions involving a Certified Nursing Assistant (CNA) who had a beard greater in length than a 5 o'clock shadow. The CNA was seen preparing and serving food without a beard restraint, which is against the FDA Food Code 2022 and the facility's own policy on culinary services dress code. The Dietary Manager confirmed that all staff are expected to wear hair and beard restraints in the food service area and that education on this expectation had been provided to all staff. On one occasion, the CNA was observed preparing cold cereal with milk and serving it to a resident without wearing a beard restraint. On another occasion, the CNA entered the kitchenette without a hair net or beard restraint, picked up a plate of food, and delivered it to a resident. When interviewed, the CNA admitted to forgetting to put on a hair net and was unsure about the requirement for a beard restraint. The Dietary Manager reiterated that hair and beard nets are available in each unit kitchenette and that all staff are expected to use them during meal service.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility did not ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Medical equipment, specifically reusable mechanical lifts, was not sanitized between uses for four residents. Certified Nursing Assistants (CNAs) were observed failing to clean the lifts after transferring residents, despite the facility policy requiring sanitization with hydrogen peroxide wipes between each resident. Interviews with staff revealed a misunderstanding or neglect of the policy, with some staff indicating that lifts were only cleaned at night rather than between each use. Inappropriate glove use was observed during medication administration for two residents. A Registered Nurse (RN) was seen wearing the same pair of gloves while touching multiple surfaces, including a computer screen, door handle, and medication containers, before applying a topical cream to a resident's face. This practice contaminated the gloves, which should have been changed, and hand hygiene performed before applying the cream. Another instance involved the same RN using gloves to handle a glucometer and lancet, touching various surfaces without changing gloves or sanitizing the touched surfaces. Additionally, there was no sanitization of a common area table after a used lancet and glucometer were placed on it during a blood glucose check for a resident. The RN placed the used items directly on the table without a barrier and did not sanitize the table afterward. Interviews with staff confirmed that the table should have been sanitized after use, and a barrier should have been used to prevent contamination. These actions and inactions led to deficiencies in maintaining a sanitary environment and proper infection control practices in the facility.
Failure to Ensure Privacy and Confidentiality of Resident Medical Records
Penalty
Summary
The facility did not ensure the privacy and confidentiality of resident medical records during medication administration. On multiple occasions, surveyors observed staff leaving the Medication Administration Record (MAR) open with resident information visible when leaving the medication cart unattended. Specifically, on 05/14/24, a Registered Nurse (RN) left the medication cart to obtain additional medication, leaving R45's information visible on the MAR. Similarly, another RN left the MAR open with R48's information visible while retrieving ice cream from the kitchenette. The same RN was also observed leaving the MAR open with R7's and R33's information visible while administering medications in the dining area. Interviews with the staff revealed that they were aware of the policy requiring the MAR to be closed when leaving the medication cart unattended but admitted to sometimes forgetting to do so due to being in a hurry. The Director of Nursing (DON) confirmed that the facility's policy mandates that the MAR should be closed to protect resident information and acknowledged the observations made by the surveyors. The DON stated that re-education of all staff who pass medications would be conducted to address this issue.
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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 West Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mulder Health Care Facility | 0.7 mi | ★★★★★ | 8 | 0 |
| Onalaska Care Center | 7.3 mi | ★★★★★ | 1 | 0 |
| Hillview Health Care Ctr | 10.7 mi | ★★★★★ | 15 | 0 |
| Benedictine Manor Of Lacrosse | 11.5 mi | ★★★★★ | 1 | 0 |
| Bethany St Joseph Care Ctr | 11.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.