R20 tested positive for coronavirus on June 2nd and received physician orders for contact and droplet isolation precautions. Her care plan instructed staff to "encourage resident to remain room." Instead, federal inspectors documented her wandering the facility for ten days.
On June 9th at 12:15 PM, inspectors observed R20 smoking on the wheelchair ramp with other residents and employees walking by. The next day, she attended resident council, removing her mask and coughing. When she walked through the hallway afterward, her cloth mask didn't cover her nose.
"Being on isolation sucks. I have COVID," R20 told inspectors. "I'm just allowed to go smoke, but not with the other residents. I have to wear a mask when I leave my room. A mask, not sure if I need special one but I have this one." She showed a multi-colored cloth mask instead of the required disposable blue surgical mask.
The facility's infection preventionist stated R20 "should be in her room with the door closed" and "can leave her room just to go smoke but must be 6 feet minimum from front of building, with no other residents." The preventionist added, "This can affect everyone at the facility. Everyone has the potential to get COVID if R20 isn't following procedure."
Staff couldn't follow basic infection control protocols because the facility failed to provide essential equipment. Neither R20's room nor R126's isolation room contained trash receptacles for disposing of protective equipment.
V15, a certified nursing assistant assigned to R126, explained she "has asked for a trash receptacle to discard PPE from management at the facility and was not given an answer." V13, a registered nurse working at the facility for three weeks, said she "has asked where to discard PPE used for R126 and has not received an answer from management."
Both staff members threw their contaminated gowns and gloves in hallway trash cans after leaving isolation rooms.
The Director of Nursing and infection preventionist acknowledged "residents on isolation should have a white trash receptacle to discard PPE inside the residents' room prior to leaving the isolation room." They stated "if staff do not have trash receptacles to discard PPE, then there is nowhere to discard used PPE."
R126, another COVID-positive resident, was ordered to use a dedicated rehabilitation bathroom in the hallway. Instead, he used his room's bathroom, which connects to two other residents' rooms. No sign redirected him to the proper bathroom. Housekeeping staff cleaned the shared bathroom once daily, unaware of the isolation requirements.
The infection preventionist noted the rehabilitation bathroom "remains unlocked at all times, and anyone can use the bathroom" with "no sign alerting staff, residents, or visitors to not use" it. She warned that "if staff, visitors, or other residents use the shared Rehab bathroom with R126, there is potential to spread infection throughout the entire facility."
Beyond infection control failures, the facility endangered residents through systematic neglect of basic care.
R132, a paraplegic resident requiring incontinence care every two hours, often went eight hours without assistance. A certified nursing assistant explained residents "might be getting up and get the incontinence care by the morning shift aide 10:30 AM, but then the resident might not get another change until next shift comes on" at 3 PM.
Three residents with contractures and mobility impairments weren't receiving ordered range-of-motion exercises. R74 complained "staff has not been giving range of motion exercises for the left arm and left leg" and worried about developing contractures from his stroke-related weakness. R57 said staff hadn't helped him with exercises "for more than 2 weeks."
The restorative aide responsible for these exercises worked from an outdated resident list and admitted he couldn't complete required treatments "because of time." Sometimes he worked on escorts or covered for absent staff instead of providing therapy.
R73, who had contractures in both hands, was supposed to wear bilateral splints for four to six hours daily. When inspectors arrived, no hand protectors were available anywhere in the facility. The restorative nurse had ordered replacements on June 9th but suggested staff could use rolled towels secured with gauze as temporary alternatives. Nobody had implemented this basic solution.
Respiratory care proved equally haphazard. R102's oxygen concentrator was set at 5 liters per minute when his physician ordered 2-3 liters. The registered nurse explained that "oxygen concentration levels set higher than physician's order recommendations can result in hyperoxygenation."
Oxygen tubing throughout the facility violated infection control standards. R124's nasal cannula hung "curled on the top of the canister" without proper containment or labeling. R24's tubing was "wrapped around the bed's rail and touching the floor" because "there was no bag to place the tubing into."
The Director of Nursing stated oxygen equipment "should be contained in a plastic bag when not in use, and labeled with a date on the bag" for infection control, but staff weren't following these protocols.
A resident's pressure ulcer prevention equipment failed when it mattered most. R71, at risk for pressure ulcers, was found lying on a completely deflated low air loss mattress because someone had turned off the power. The Assistant Director of Nursing acknowledged "if it's not turned on, it cannot work for the resident."
Medication storage violated federal controlled substance requirements. Lorazepam, a Schedule IV controlled substance, was stored in an unlocked refrigerator. The lock was "on the floor." Completed controlled substance orders from June 4th remained in facility storage instead of being returned to the pharmacy as required.
Shift-to-shift narcotic counts showed missing signatures on June 7th and 8th, indicating nurses weren't properly accounting for controlled medications during shift changes.
The facility's 150 residents faced additional risks from basic sanitation failures. Two of three outdoor dumpsters were overfilled with lids partially open, creating pest infestation risks. Expired milk cartons from early May remained in the walk-in cooler in June.
Kitchen staff left wet cleaning rags on food preparation surfaces instead of keeping them in sanitizing solution. Four residents' personal refrigerators lacked thermometers or temperature logs, preventing staff from ensuring food safety.
The laundry area posed fire hazards. The dryer's lint trap contained "large buildup of lint" with no cleaning schedule. The Housekeeping Director admitted "I check it when I can. I don't know when I'm not here who checks it" and acknowledged lint buildup "could overheat the dryer and cause a fire."
Federal inspectors cited the facility for eight separate violations affecting dozens of residents. The inspection revealed systematic breakdowns in infection control, medication management, therapeutic care, and basic safety protocols that put all 150 residents at risk.
R20's case exemplified the broader failures. Despite testing positive for a highly contagious respiratory virus, she roamed freely through common areas because staff lacked basic supplies and management failed to enforce isolation protocols that could have protected every resident in the building.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakeview Rehab & Nursing Center from 2025-06-12 including all violations, facility responses, and corrective action plans.
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