Lakeside Center For Rehabilitation And Healing

Based on record review and interviews, the facility failed to ensure the Director of Nursing (DON) did not serve in the position of a charge nurse when the facility's census was greater than 60.

Review of the facility staffing schedule dated 8/14/25 revealed that the DON was scheduled to work 7:00 pm - 7:00 am on the 500/600 hall cart.

The census was noted as 116.

During an interview on 8/14/25 at 11:55 am, the certified nursing assistant (CNA)/staffing coordinator, stated she used the facility census to plan for the staffing.

She confirmed that the DON was scheduled to work tonight (8/14/25).

She explained that the facility had a nurse shortage therefore the DON helped out on open slots.

When asked how often the DON worked on the floor, she stated that she had to review the schedule.On 8/14/25 at 2:25 pm, the DON confirmed that she had been working on the floor when there is a need.

She stated that the night shift had been the issue most of the time.

She explained that she had worked at least 2-3 times a month. In an interview with the Administrator on 8/14/25 at 3:15 pm, he confirmed that the DON had worked the following dates: 6/9/25 (census 114), 6/10/25 (census 114), and 6/12/25 (census 112). (Copies obtained)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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