Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeview Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that insulin pens on two medication carts were not properly labeled or dated. On one cart, a Lantus Solostar insulin pen lacked an opened date, and an LVN acknowledged insulin should be dated because it is only effective for 28 days after opening. On another cart, a Tresiba FlexTouch insulin pen had neither a resident name nor an opened date; an LVN reported it was likely from the emergency kit and confirmed it should have been labeled with the resident’s name and open date. The DON stated her expectation that all insulin pens, including those from the emergency kit, be labeled with the resident’s identifying information and the date opened to prevent use of expired or incorrect insulin.
A resident with a stage 4 pressure ulcer experienced inadequate pain management during wound care after a debridement procedure. Despite a care plan that included pain medications and lidocaine application, the facility failed to consistently administer these interventions, leading to significant pain during treatments. Staff interviews revealed lapses in communication with the physician and inconsistent application of pain relief measures, contrary to the facility's pain management policy.
A resident experienced increased pain following a wound debridement, but the facility failed to notify the physician promptly. Despite the resident's complaints and requests for stronger pain medication, the staff did not contact the physician until several days later, leading to inadequate pain management.
A facility failed to maintain consistent communication with a dialysis center for a resident with end-stage renal disease, missing several dialysis communication forms. The resident was scheduled for dialysis three times a week, but the facility did not consistently send or receive the necessary communication forms, which are essential for monitoring the resident's condition. Staff interviews revealed lapses in completing these forms, and the facility lacked a monitoring system to ensure compliance with its dialysis protocol.
The facility's kitchen failed to meet food safety standards, with issues such as a dirty fryer, improperly stored and labeled food, and a lack of temperature monitoring in the dining room freezer. The Dietary Manager and staff were unaware of these deficiencies, and cleaning logs showed non-compliance with established procedures.
A resident with severe cognitive impairment and multiple health conditions was found to have their call light repeatedly out of reach, despite being dependent on staff for assistance. The facility's staff, including a CNA and the DON, acknowledged the importance of call light accessibility, yet the deficiency persisted, indicating a failure to accommodate the resident's needs.
The facility failed to maintain a clean and homelike environment in the back dining room, as evidenced by cobwebs, dead bugs, and dust on the windowsill. The Housekeeping Supervisor and Administrator acknowledged the oversight, noting that the windowsills should be cleaned multiple times a week. The facility's policy emphasizes the importance of a clean and orderly environment.
A resident with end-stage renal disease was receiving dialysis three times a week, but this was not reflected in her MDS assessment. The DON and MDS Coordinator acknowledged the oversight, which could affect care monitoring. The Administrator stressed the importance of accurate MDS coding for proper reimbursement and care representation.
A facility failed to update a resident's care plan to include necessary interventions for weight loss, such as weekly weights and Ensure Plus administration, despite these being part of the resident's physician orders. Interviews with staff revealed confusion over responsibility for care plan updates, with the MDS Coordinator admitting to missing these critical interventions. The facility's policy requires care plans to be comprehensive and revised as conditions change, which was not followed in this instance.
A resident with hemiplegia and a UTI was found with wet bed sheets and clothing due to inadequate incontinent care. Despite being on antibiotics, the resident required substantial assistance with toileting. Observations revealed that staff did not perform timely rounds, leading to the resident remaining wet overnight. Interviews highlighted the importance of prompt care to prevent skin breakdown and infection, but there was a lack of communication and documentation regarding the resident's care needs.
A facility failed to provide trauma-informed care for a resident with PTSD, as staff were unaware of the resident's triggers and did not document them in the care plan. Despite the resident's history of paranoid schizophrenia, PTSD, and other mental health conditions, the facility did not adequately assess or address his trauma history, leading to potential re-traumatization. Interviews with staff revealed a lack of awareness and documentation regarding the resident's PTSD diagnosis and triggers, contrary to the facility's policy on trauma-informed care.
Two residents received blood pressure medications outside of ordered parameters, leading to significant medication errors. A resident with renal disease was given amlodipine despite low blood pressure, and another with cerebral infarction received carvedilol under similar conditions. The LVN involved was aware of the parameters but followed incorrect training advice. The DON admitted to a lack of monitoring systems, and the Administrator emphasized the need for protocol adherence.
The facility failed to maintain proper infection control when Laundry Aide H distributed clean clothing with a partially covered linen cart, exposing the clothes to potential contamination. Interviews revealed that the aide was aware of the need for complete coverage but believed the blanket used was adequate. The Housekeeping Supervisor and Administrator confirmed the requirement for full coverage to prevent exposure to germs, aligning with the facility's policy.
Improper Labeling and Dating of Insulin Pens on Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling, labeling, and dating of insulin pens on two medication carts. On the East Hall medication cart, a Lantus Solostar pre-filled insulin pen was observed without an opened date. When interviewed, LVN A stated she did not know why the insulin was not dated and acknowledged that insulin should be dated when opened because it is only good for 28 days after opening. The facility’s Medication Administration policy indicated that medications are to be administered safely and as prescribed, and that insulin pens containing multiple doses are for single-resident use only. On the [NAME] Hall medication cart, surveyors observed a Tresiba FlexTouch insulin pen without a resident name or opened date. LVN B stated the pen was probably from the emergency kit and confirmed that insulin from the emergency kit should be labeled with the resident’s name and an open date to ensure the correct person receives the correct medication and because insulin pens are only good for 28 days after opening. The DON stated she expected insulin pens labeled by the pharmacy with a resident’s name to be dated when opened, and that pens taken from the emergency kit should be labeled with the resident’s name, date of birth, and the date opened. The DON further stated that dating insulin ensures residents are not given expired or ineffective medication and that labeling each pen with the correct resident name ensures the right person receives the right medication.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident during wound care, specifically after a wound debridement procedure. The resident, who had a stage 4 pressure ulcer, reported increased pain following the debridement performed by the Wound Care NP. Despite having a care plan that included administering pain medication prior to treatments, the facility did not consistently ensure that the resident received appropriate pain relief, leading to the resident experiencing significant pain during wound care procedures. The resident's medical history included conditions such as low back pain, gout, and rhabdomyolysis, and he was dependent on staff for various activities of daily living. The resident's care plan specified the use of medications like oxycodone, hydrocodone-acetaminophen, and Tylenol for pain management, as well as the application of lidocaine prior to wound care. However, the facility's staff did not consistently apply these interventions, and there were lapses in communication with the physician regarding the resident's increased pain following the debridement. Interviews with facility staff revealed that the resident had been experiencing increased pain since the debridement, but the staff did not promptly notify the physician or adjust the pain management plan accordingly. The resident expressed that the pain was severe during wound care, describing it as a burning sensation, yet the staff did not consistently apply lidocaine or ensure the effectiveness of the pain medications administered. The facility's policy on pain management was not adequately followed, resulting in the resident enduring unnecessary pain during wound care procedures.
Failure to Notify Physician of Increased Pain Post-Debridement
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's condition, specifically increased pain following a wound debridement. The resident, who had a stage 4 pressure ulcer, experienced increased pain after the procedure performed by the Wound Care NP. Despite the resident's complaints of increased pain, the facility did not inform the physician promptly, which could have led to inadequate pain management. The resident's medical records indicated that he was receiving various pain medications, including oxycodone and hydrocodone, but there was no documentation of increased pain or the debridement procedure in the progress notes. The resident reported increased pain during wound care, describing it as a burning sensation, and requested stronger pain medication. However, the facility staff did not contact the physician until several days later to address the resident's pain management needs. Interviews with facility staff revealed that the resident's pain was not adequately assessed or communicated to the physician. The staff acknowledged the resident's increased pain but failed to take timely action to adjust the pain management plan. The facility's policy on pain management emphasized the importance of addressing pain and notifying the physician of any changes, but this was not followed in the resident's case.
Failure in Dialysis Communication for a Resident
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center for a resident requiring dialysis services. The resident, a female with end-stage renal disease, was scheduled to receive dialysis three times a week. However, the facility did not consistently send or receive dialysis communication forms on multiple occasions, which are crucial for monitoring the resident's condition and ensuring proper care. Interviews with staff revealed that the dialysis communication sheets were not consistently completed or sent. The charge nurse at the dialysis clinic noted that sometimes they received the communication sheets and sometimes they did not. The facility's LVN acknowledged the importance of these sheets for communication and monitoring but admitted that some sheets might have been missed, especially after the resident was moved to a different room. The Director of Nursing (DON) and the Administrator both recognized the importance of the dialysis communication forms for ensuring proper communication and monitoring of the resident's condition. However, there was no monitoring system in place to ensure that the communication forms were consistently completed and sent. The facility's policy required a communication form to accompany the resident to and from the dialysis center, but this protocol was not consistently followed.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain food safety standards in its kitchen, as observed during a survey. The cooking area was found to have a dirty fryer with dark oil and crumbs, and a toaster with crumbs around it. In the dry storage room, an opened loaf of bread was improperly sealed and not dated, and an opened container of enchilada sauce was not refrigerated as required. In the right freezer, an opened box of corn dogs was not sealed properly, resulting in freezer burn. The refrigerator in the kitchen contained an opened box of bacon that was not sealed, and a container of leftover beans that was not discarded after the appropriate time. Additionally, a gallon of chocolate milk was found past its best-by date. The survey also revealed that the top freezer in the dining room lacked a thermometer, and its temperature was not being monitored. The freezer contained 18 loaves of frozen bread and had a thick brown residue on the second shelf of the door, which had leaked onto the bottom. Dietary staff were not aware of the need to monitor the freezer's temperature separately from the refrigerator. The Dietary Manager admitted to not being aware of the residue and the lack of a thermometer, and acknowledged that the dietary staff should have been monitoring temperatures and cleaning the freezer. Interviews with the Dietary Manager and Administrator highlighted a lack of adherence to food safety protocols. The Dietary Manager admitted to cleaning the fryer only once a week and not ensuring that opened food items were properly sealed and dated. The Administrator expected food to be covered, sealed, and dated, and for temperatures to be monitored to prevent serving spoiled food. The facility's cleaning logs and policies indicated a lack of compliance with established procedures for food storage and cleanliness, contributing to the deficiencies observed during the survey.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach while the resident was in bed, which is a deficiency in accommodating the needs and preferences of the resident. The resident, a male with severe cognitive impairment and multiple health conditions including vascular dementia and the absence of both legs above the knee, was dependent on staff for various activities of daily living. The care plan for the resident indicated that he was at high risk for falls and required his call light to be within reach to request assistance. However, during multiple observations, the call light was found on the floor, out of the resident's reach, which could delay assistance and decrease the resident's quality of life. Interviews with staff, including a CNA and the DON, revealed that the staff were aware of the importance of ensuring call lights were within reach for residents to communicate their needs. The DON acknowledged that the call light should be within reach when staff leave the room, and the Administrator emphasized that the call light is the resident's only means of communication. Despite this understanding, the call light was repeatedly found out of reach, indicating a failure in the facility's responsibility to ensure reasonable accommodation of the resident's needs.
Failure to Maintain Cleanliness in Dining Room
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment in the back dining room, as evidenced by the presence of numerous cobwebs, dead bugs, and a thick layer of gray dust on the windowsill. This condition was observed on three separate occasions over a three-day period. The Housekeeping Supervisor acknowledged that the housekeeping staff, including herself, were responsible for cleaning the dining room, which included the blinds, windowsills, and walls. However, she admitted that the windowsill had not been cleaned due to time constraints. The Administrator confirmed that the housekeeping staff were tasked with ensuring the cleanliness of the back dining room and stated that the windowsills should have been cleaned at least three to four times per week. The Administrator noted that the facility had recently removed decorations to add fall decorations but had not yet cleaned the windowsill. Both the Housekeeping Supervisor and the Administrator emphasized the importance of maintaining a clean environment to prevent cross-contamination and promote resident happiness and comfort. The facility's Homelike Environment policy, revised in February 2021, reflects the expectation of a clean, sanitary, and orderly environment.
Inaccurate MDS Assessment for Dialysis Treatment
Penalty
Summary
The facility failed to ensure that the MDS assessment for a resident accurately reflected her dialysis treatments. The resident, who was diagnosed with end-stage renal disease, was receiving dialysis three times a week at a dialysis center. However, the Quarterly MDS assessment did not indicate that the resident was receiving dialysis, which was a significant oversight. The Director of Nursing (DON) and the MDS Coordinator both acknowledged that the dialysis should have been coded on the MDS assessment, but it was missed. This inaccuracy in the MDS assessment could potentially affect the monitoring and care provided to the resident. Interviews with the DON and the MDS Coordinator revealed that they were responsible for reviewing and signing the MDS assessments. The DON admitted to possibly missing the dialysis entry, while the MDS Coordinator confirmed that the dialysis should have been included. The Administrator emphasized the importance of accurate MDS coding for proper reimbursement and to ensure that the resident's care needs were accurately represented. The facility's MDS Coding Policy requires the use of the most up-to-date Resident Assessment Instrument manual for accurate coding, which was not adhered to in this case.
Failure to Update Resident's Care Plan for Weight Loss Interventions
Penalty
Summary
The facility failed to ensure that a resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. Specifically, the care plan for a resident with diagnoses including anxiety, protein-calorie malnutrition, muscle wasting, and dysphagia was not updated to reflect the need for weekly weights and the administration of Ensure Plus three times a day. This oversight was identified during a record review and interviews with facility staff, revealing that the care plan did not include these critical interventions despite being part of the resident's physician orders. Interviews with facility staff, including an LVN, the DON, the Administrator, and the MDS Coordinator, highlighted a lack of clarity regarding responsibility for updating care plans. The MDS Coordinator acknowledged missing the inclusion of the resident's weight loss interventions in the care plan, which was crucial for ensuring proper care by CNAs. The facility's policy mandates that care plans be comprehensive, person-centered, and revised as residents' conditions change, but this was not adhered to in this case.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, leading to a deficiency in care. The resident, a male with a history of hemiplegia and hemiparesis following a cerebral infarction, was found with wet bed sheets and clothing up to his shoulders, with brown edges around the wet spots. This incident occurred on the morning of 11/18/24, and the resident reported having been wet all night. The resident had a urinary tract infection diagnosed on 11/13/24, and was on antibiotic treatment. Despite the resident's ability to communicate and use a urinal, he required substantial assistance with toileting hygiene and was frequently incontinent of urine. Observations and interviews revealed that the facility staff did not perform timely incontinent care for the resident. The CNAs responsible for the resident's care acknowledged the wet condition of the bed and the need for a full linen change. However, there was uncertainty about when the last rounds were completed by the night shift, and the day shift staff only began their rounds after breakfast. The CNAs and LVN interviewed emphasized the importance of prompt incontinent care to prevent skin breakdown and worsening of infections, but there was a lack of communication and documentation regarding the resident's condition and care needs. The facility's Director of Nursing and Administrator stated that incontinent rounds should be completed regularly, with specific expectations for the timing of rounds. However, there was a discrepancy in the execution of these rounds, as evidenced by the resident's condition. The Regional Nurse reported that the night shift NA claimed to have checked the resident early in the morning, but no documentation was provided to support this claim. The facility's policy for bladder incontinence was requested but not provided, indicating a potential gap in procedural adherence or documentation.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care, specifically for one resident who was reviewed for trauma-informed care. The resident, a male with a history of paranoid schizophrenia, PTSD, personality disorder, and major depression, was not adequately assessed for his history of trauma. The comprehensive care plan for this resident did not address his PTSD triggers, which could potentially lead to re-traumatization and severe psychological distress. Interviews with various staff members, including a Licensed Vocational Nurse (LVN), Social Worker (SW), Minimum Data Set (MDS) Coordinator, Certified Nursing Assistant (CNA), Director of Nursing (DON), and the Administrator, revealed a lack of awareness and documentation regarding the resident's PTSD diagnosis and triggers. The LVN and SW were unaware of the resident's specific triggers, and the MDS Coordinator acknowledged that the care plan should include identified triggers to ensure proper care. The CNA and DON also emphasized the importance of staff being aware of any triggers to provide appropriate care. The facility's policy on trauma-informed and culturally competent care requires universal screening of residents for possible exposure to traumatic events and the development of individualized care plans that address past trauma. However, the policy was not effectively implemented, as evidenced by the lack of documentation and awareness of the resident's PTSD triggers. This oversight could lead to re-traumatization and negatively impact the resident's quality of life.
Medication Administration Errors for Blood Pressure Medications
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors related to the administration of blood pressure medications. Resident #13, a female with end-stage renal disease and hypertension, was administered amlodipine despite her blood pressure being below the ordered parameters. The medication was given by LVN G when Resident #13's systolic blood pressure was 99, which was below the threshold of 100 as per the physician's order. Similarly, Resident #41, a female with cerebral infarction, atrial fibrillation, and hypertension, was administered carvedilol when her blood pressure was also below the ordered parameters. LVN G administered the medication when Resident #41's systolic blood pressure was 95, below the required threshold of 100. Both instances of medication administration were contrary to the physician's orders, which specified holding the medication if the blood pressure was below certain levels. Interviews revealed that LVN G was aware of the parameters but administered the medications based on her judgment and training from other nurses, who advised giving the medication if the blood pressure was borderline. The Director of Nursing (DON) acknowledged that the medications should not have been administered outside the parameters and admitted there was no system in place to monitor medication administration compliance. The Administrator expected adherence to proper protocols and indicated that the DON was responsible for oversight, with the RN supervisor monitoring on weekends.
Inadequate Linen Cart Coverage During Laundry Distribution
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of a linen cart by Laundry Aide H. During an observation, it was noted that Laundry Aide H was distributing clean clothing to residents with the linen cart only partially covered by a blanket, leaving the clothing exposed. This action was contrary to the facility's policy, which requires that clean linen carts be completely covered to prevent environmental contamination and ensure the clothes remain hygienically clean. Interviews with Laundry Aide H and the Housekeeping Supervisor revealed that Laundry Aide H was aware that the linen cart should be completely covered to prevent exposure to germs, but mistakenly believed the blanket used was sufficient. The Housekeeping Supervisor confirmed that a flat white sheet should be used to cover the linen cart completely. The Administrator also emphasized the importance of covering the linen cart to protect the clothes from pathogens and dirt during transport from the laundry room to residents' closets. The facility's policy on laundry and linen handling, reviewed in January 2023, supports these practices to maintain a safe and aseptic environment.
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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 Winnsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Winnsboro | 0.1 mi | — | 0 | 0 |
| Quitman Wellness & Rehabilitation | 13.4 mi | — | 0 | 0 |
| Cypress Springs Wellness & Rehabilitation | 16.7 mi | — | 3 | 0 |
| Avir At Pittsburg | 19.4 mi | — | 1 | 0 |
| Rock Creek Health And Rehabilitation | 20.9 mi | — | 4 | 1 |
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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.