Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before 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 Lakeland Village Nursing Facility during CMS and state inspections, most recent first.
A resident with profound intellectual disability and PICA ingested an exam glove after gloves were left accessible in a bathroom drawer and a nearby trash can. Despite a care plan requiring 1:1 supervision, staff interviews and observations confirmed that the resident could easily access hazardous items, and no changes were made to storage practices following the incident.
A resident with intellectual disability and dementia did not receive a physician-ordered Epsom salt foot soak for a toe infection, despite documentation by an LPN indicating it was completed. Multiple staff accounts and facility investigation determined the treatment was not performed as ordered, resulting in a failure to provide necessary medical care.
A resident with cognitive impairment and high care needs experienced a fall and head injury, which was witnessed by staff. Despite facility policy, staff did not complete an incident report or notify a nurse for assessment, following instructions from a manager. No documentation or report of the incident was found in facility records, resulting in a failure to report the event to proper authorities.
The facility failed to protect two residents from abuse. A cognitively impaired resident was reportedly abused by an RN, resulting in a red mark on their chest. Another resident, unable to direct their own care, was assaulted by a fellow resident due to inadequate supervision when a staff member left their post for a lunch break.
Two residents with severe cognitive impairment were left in urine-soaked clothing, leading to skin issues. Despite care plans requiring frequent checks, staff failed to change the residents promptly, resulting in skin excoriation and moisture-associated rash. Staff interviews confirmed awareness of the residents' conditions but inaction in providing timely care.
The facility failed to test modified fluid consistencies for residents at risk of aspiration, leading to coughing incidents. Staff did not verify thickened fluids using recommended methods, relying instead on visual assessment. Additionally, food storage and preparation practices were inadequate, with improper labeling and temperature monitoring, and dishwasher temperatures were below required levels. Staff also neglected to wear hair nets over facial hair, risking contamination.
The facility failed to review infection control policies annually, maintain proper hand hygiene, and implement transmission-based precautions. Observations revealed outdated policies, inadequate hand hygiene practices, and improper handling of soiled laundry. A resident with a feeding tube did not have appropriate signage for enhanced barrier precautions, and staff were observed not following proper PPE protocols.
The facility failed to ensure all staff involved in food preparation had valid food handler's cards, with staff in six out of seven cottages preparing food without these certifications. Additionally, one dietary staff member had an expired card. This oversight posed a potential risk for unsafe food handling practices, placing residents at risk for foodborne illnesses.
A resident with a psychotic disorder was prescribed and received Duloxetine, a psychotropic medication, without documented informed consent. The facility did not ensure that the resident or their representative was informed of the medication's risks and benefits prior to administration, as confirmed by the DON.
The facility failed to transmit MDS assessments for two residents with severe cognitive impairments to CMS within the required timeframe. The assessments were completed but not accepted due to unknown reasons, as confirmed by a CMRN and the DON.
A facility failed to prevent and manage pressure ulcers for a resident, leading to a worsening condition. The resident was found sitting on multiple layers, including a Hoyer sling, which increased pressure risk. Staff interviews revealed a lack of understanding about proper pressure relief management, contributing to the deficiency.
The facility failed to report an allegation of potential abuse to the State Agency within the required timeframe. A CNA reported overhearing a staff member yelling at a resident, but the incident was not reported until several hours later, exceeding the two-hour reporting requirement. The DON acknowledged the delay, which violated state regulations.
A resident with bipolar disorder and intellectual disability was verbally abused by an LPN, who yelled at them to wake up and take medication. The incident was reported by a nursing assistant, but the LPN continued to work with the resident without immediate protective measures. The resident was not assessed for psychological harm until the following day, highlighting a deficiency in the facility's response.
A resident with intellectual and mental health disorders was neglected in a facility, as they were left in a soaked incontinence brief for hours and only given fruit for breakfast. Despite being dependent on staff for toileting and meal setup, the resident was not assisted out of bed until late morning, leading to emotional distress and a diminished quality of life.
A resident with intellectual and mental health disorders was allegedly neglected by a lead Nursing Assistant. The incident was reported internally by staff but not to the State Agency within the required two-hour window, as staff were unaware of the reporting timeline. This delay in reporting placed residents at risk.
The facility failed to promptly investigate allegations of neglect involving two residents with significant medical and physical needs. Concerns were initially reported by nursing staff, but the facility's response was delayed, allowing the alleged perpetrator to continue working with the residents for several days. This inaction placed the residents at risk for continued neglect.
Failure to Prevent Ingestion of Hazardous Items by Resident with PICA
Penalty
Summary
The facility failed to consistently implement interventions to prevent a resident with profound intellectual disability and PICA from ingesting non-food items, specifically an exam glove. The resident's care plan indicated a need for 1:1 staff supervision at all times to prevent ingestion of unsafe items, as the resident was known to be very sly and able to obtain items that were not digestible. Despite this, observations and interviews revealed that nitrile exam gloves were stored in an easily accessible drawer in the resident's bathroom and that a small trash can containing used gloves and paper towels was within reach in the resident's room. Staff confirmed that the resident had good hand dexterity, could move quickly, and would attempt to grab items within their vicinity. On one occasion, a nursing assistant discovered an intact nitrile exam glove in the resident's ileostomy stool pouch, indicating that the resident had ingested the glove. Further review of the facility's investigation and staff interviews confirmed that no changes had been made to the storage of gloves or the trash can following the incident. The staff responsible for 1:1 supervision stated that they were required to remain within arm's reach and maintain constant eyesight of the resident, acknowledging the resident's ability to quickly access and ingest items. The facility was unable to determine exactly how or when the ingestion occurred, but the presence of accessible gloves and inadequate environmental controls contributed to the deficiency.
Failure to Provide Ordered Medical Treatment for Resident's Toe Infection
Penalty
Summary
A resident with moderate intellectual disability and dementia was admitted to the facility and developed a discolored and tender right great toe. The facility physician was notified, and a verbal order was given to start Epsom salt soaks for the affected toe. The order was later updated to continue the soaks and add an antibiotic due to signs of infection, including erythema and open drainage. Documentation in the medication administration record indicated that the foot soak was completed as ordered on the evening shift; however, multiple staff statements and facility investigation revealed that the treatment was not actually performed during that shift. Further review showed that the resident was present in common areas during the time the soak was supposed to occur, and staff who were present did not witness the treatment being provided. Additionally, a nursing assistant noted that the bandage on the resident's toe appeared used and dry, inconsistent with a recent soak. The facility's investigation concluded that it was more likely than not that the ordered foot soak was not completed as documented, resulting in a failure to provide medical care as ordered and a possible diminished quality of life for the resident.
Failure to Timely Report and Document Resident Fall
Penalty
Summary
The facility failed to ensure timely reporting and documentation of an allegation of neglect involving a cognitively impaired resident with moderate intellectual disabilities and schizoaffective disorder, who required maximum assistance for activities of daily living. Multiple staff members witnessed or were informed of the resident falling out of bed and hitting their head, but did not follow established procedures for reporting and responding to such incidents. Staff B and Staff C both observed or were aware of the fall, but were instructed by Staff E, an Attendant Counselor Manager, not to complete an incident report, despite facility policy requiring incident reporting and nurse assessment before moving the resident. Staff B and Staff C did not escalate their concerns or report the incident further, citing fear of reprisal and uncertainty about the process. Staff E, upon being informed of the resident being on the floor, did not believe the incident was reportable and did not ensure a nurse assessment or incident report was completed. Staff D, another manager, was later informed of the incident but also did not report it to higher authorities. Review of facility records confirmed there was no documentation or incident report regarding the resident's fall and head injury during the relevant period. This lack of timely reporting and documentation resulted in a failure to notify proper authorities and ensure appropriate follow-up for the resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in potential physical and psychological harm. Resident 1, who was cognitively impaired and required one-to-one supervision, was reportedly subjected to physical abuse by a registered nurse (RN). Witnesses observed the RN pushing on Resident 1's chest while attempting to administer medication, resulting in a red mark on the resident's chest. This incident was corroborated by multiple staff members who confirmed the presence of the mark and the actions of the RN. Resident 2, who was unable to direct their own care and dependent on staff for most activities of daily living, was left unsupervised, leading to an assault by another resident. Staff members witnessed Resident 3 hitting Resident 2, resulting in a reddened area and scratches on Resident 2's neck. The incident occurred because a staff member left their post for a lunch break without ensuring another staff member was present to monitor the residents, contrary to the facility's staffing expectations.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to potential skin injury and decreased quality of life. Resident 1, with severe cognitive impairment and dependent on staff for daily activities, was found with red and bleeding skin on the buttocks after being left in urine-soaked clothing. Staff interviews revealed that Resident 1 was not changed for several hours, despite being aware of the resident's wet condition. The care plan required frequent toileting assistance, but this was not adhered to, resulting in skin excoriation. Resident 2, also with severe cognitive impairment and dependent on staff, was found in urine-soaked clothing and wheelchair pad. The resident had a moisture-associated rash, which was documented in nursing progress notes. Staff interviews indicated that Resident 2 was not changed for an extended period, despite the care plan's requirement for frequent checks and changes to prevent skin breakdown. Staff acknowledged awareness of the resident's wet condition but failed to act promptly. The deficiency was identified through interviews and record reviews, highlighting a lapse in professional standards of practice. Both residents were at risk of skin injury due to prolonged exposure to moisture, and the facility's failure to adhere to care plans and timely incontinence care contributed to the residents' compromised skin integrity.
Failure to Ensure Safe Food and Fluid Consistency Practices
Penalty
Summary
The facility failed to test modified fluid consistencies after preparation and before serving to vulnerable residents at risk for aspiration. This deficiency was observed in three of nine sampled residents who required specific liquid consistencies due to swallowing difficulties. The facility's policy followed the International Dysphagia Standardization Initiative (IDDSI) for texture descriptions and terminology, but staff did not consistently verify the accuracy of thickened fluids before serving them to residents. For instance, Resident 8, who required extremely thick liquids, was served fluids that were not tested for consistency, leading to coughing during meals. Staff relied on visual assessment rather than using the IDDSI flow test or other recommended methods to ensure the correct consistency. Additionally, the facility failed to ensure that foods were stored and prepared in a safe manner, which placed residents at risk for foodborne illness. Observations revealed that food items in the main kitchen and various cottages were not properly labeled with dates, and refrigerator and freezer temperatures were not consistently monitored or documented. In some cases, temperature probes were not correctly placed, leading to inaccurate readings. The facility's policy required food to be labeled with preparation and use-by dates to prevent bacterial growth, but this was not consistently followed. The facility also failed to maintain the required dishwasher temperatures, which are necessary to kill bacteria and ensure sanitary conditions. The dishwasher logs showed multiple instances where the final rinse temperature did not reach the required 180 degrees Fahrenheit. Furthermore, staff working in the kitchen were observed not wearing hair nets over facial hair, which is necessary to prevent contamination. These deficiencies in food storage, preparation, and sanitation practices compromised the safety and quality of life for all residents in the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, as evidenced by several deficiencies observed during the survey. The facility did not review its infection control policies annually as required, with the Antibiotic Stewardship Program and Infection Prevention and Control Program policies last reviewed in August 2022. Additionally, the facility's handling and washing of soiled laundry policy was outdated, and staff were not consistently wearing appropriate personal protective equipment (PPE) when handling soiled laundry. Observations in the laundry rooms revealed a lack of organization and separation between clean and dirty areas, with clean clothes left uncovered and exposed to potential contamination. Hand hygiene practices were also found to be inadequate. Staff members were observed failing to perform hand hygiene at critical moments, such as before and after resident contact, after touching potentially contaminated surfaces, and before donning gloves. Specific instances included staff serving food, checking temperatures, and assisting residents without washing hands or using hand sanitizer. These lapses in hand hygiene increased the risk of cross-contamination and the spread of infections among residents and staff. The facility also failed to implement proper transmission-based precautions for residents at risk of multidrug-resistant organisms (MDROs). For example, Resident 14, who had a feeding tube and required assistance with all activities of daily living, did not have appropriate signage indicating the need for enhanced barrier precautions. Staff were observed exiting the resident's room wearing gowns and gloves, which were not removed before leaving the room, and there was a lack of clear instructions for staff regarding the precautions to be taken. This oversight in implementing enhanced barrier precautions could lead to the transmission of MDROs within the facility.
Deficiency in Food Safety Certification for Staff
Penalty
Summary
The facility failed to ensure that all staff involved in food preparation had valid food handler's cards, which are necessary certifications indicating completion of food safety training. In six out of seven cottages, staff were observed preparing and cooking food without these cards. Specifically, staff in the Ponderosa and Rosewood Cottages were found to be handling uncooked, pasteurized eggs. Interviews with various staff members, including Attendant Counselor Managers and a Licensed Practical Nurse, revealed that while staff received food service training, they were not required to obtain the state-issued food handler's card. The Director of Nursing and the Administrator acknowledged the presence of raw eggs in the cottages and the necessity for staff preparing food to have food handler's cards. Additionally, within the dietary department, one of the 24 dietary staff members, identified as Staff C, was found to have an expired food handler's card. Despite this, Staff C was observed preparing food in the main kitchen. The Dietary Manager confirmed that a current Washington State Food Handler's card was required for all kitchen staff and acknowledged the lapse in Staff C's certification. This oversight in maintaining up-to-date food safety certifications for staff involved in food preparation posed a potential risk for unsafe food handling practices, thereby placing residents at risk for foodborne illnesses.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was informed of the potential risks associated with the use of psychotropic medications. Resident 72, who had a diagnosis of a psychotic disorder, was prescribed and received the psychotropic medication Duloxetine daily. However, there was no documentation or informed consent form completed to indicate that the risks and benefits of taking this medication were discussed with the resident or their representative prior to administration. This oversight was confirmed by the Director of Nursing, who acknowledged that informed consents for psychotropic medications should be completed before the resident receives the medication.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for two residents. Resident 12, who has idiopathic hydrocephalus and autistic disorder, had a quarterly assessment completed on 07/20/2024, but the status was not accepted by CMS. Similarly, Resident 60, diagnosed with tuberous sclerosis and mental disorders, had an annual assessment completed on 07/20/2024, which also was not accepted. Both residents have severe cognitive impairments and require substantial assistance with activities of daily living. Staff R, a Case Manager Registered Nurse, acknowledged that the assessments for both residents were completed but not accepted by CMS. The assessments were reportedly compressed into a batch file and sent to CMS on 07/22/2024, but for unknown reasons, they were lost and not accepted. Staff R and the Director of Nursing confirmed that the MDS assessments should have been submitted within the required timeframe, but there was no documentation to show that the assessments were accepted by CMS.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement appropriate interventions to prevent and heal pressure ulcers for a resident, identified as Resident 32. The resident was at risk for skin breakdown, and the care plan instructed staff to assist with activities of daily living, ensure an anti-pressure mattress was in place, and assist with turning and repositioning. However, the care plan did not document that Resident 32 had a pressure ulcer. Upon returning from the hospital, the resident was found to have a red and blanchable area on the coccyx, which was incorrectly identified as a pressure ulcer. Subsequent assessments documented changes in the condition of the wound, including it becoming open and increasing in size. Observations noted that the resident was sitting on multiple layers, including a Hoyer sling and cloth pad, which increased the risk of pressure. Interviews with staff confirmed that the Hoyer sling was not removed after transferring the resident to a wheelchair, which interfered with pressure relief and potentially delayed wound healing. Staff interviews revealed a lack of understanding regarding the proper management of pressure relief. The Director of Nursing acknowledged that residents should not sit or lay on cloth pads or Hoyer lift slings as it reduces the effectiveness of pressure-relieving cushions and mattresses, potentially worsening pressure ulcers. This deficiency placed other residents at risk for developing pressure ulcers and unmet care needs.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of potential abuse immediately to the State Agency as required, involving one of the three sampled residents. On August 6, 2024, at 7:25 AM, the Attendant Counselor Manager, Staff B, received an email from a Certified Nursing Assistant, Staff C, who reported overhearing Staff D yelling at a resident on August 5, 2024, at approximately 4:30 AM. However, the facility did not report this incident to the State Survey Agency until August 6, 2024, at 12:13 PM, exceeding the required two-hour reporting timeframe. During an interview on September 11, 2024, the Director of Nursing, Staff A, acknowledged the delay in reporting the possible abuse, which is a violation of the Washington Administrative Code (WAC) 388-97-0640 (5)(a).
Failure to Protect and Monitor Resident After Verbal Abuse Allegation
Penalty
Summary
The facility failed to protect, assess, and monitor a resident after an allegation of verbal abuse. The incident involved a resident with Rapid Cycle Type 2 Bipolar Disorder and Moderate Intellectual Disability. On the night shift, a nursing assistant overheard an LPN yelling at the resident to wake up and take medication, which left the resident appearing upset. The nursing assistant reported the incident to their supervisor via email the following morning. Despite the report, the LPN continued to work with the resident the next night, and no immediate protective measures were taken. The resident was not assessed for psychological harm until the morning after the second shift, and a nursing assessment for physical injury was conducted later that day. The delay in addressing the situation and monitoring the resident for potential harm constituted a deficiency in the facility's response to the abuse allegation.
Neglect of Resident's Incontinence Care and Meal Provision
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, as evidenced by the lack of timely incontinence care and inadequate provision of a morning meal. The resident, who had a history of moderate intellectual disability, schizoaffective disorder, and bipolar disorder, was dependent on staff for toileting and meal setup. On the morning of the incident, the resident was found by a nursing assistant to be incontinent of urine, with their incontinence brief soaked and leaking onto the bed. Despite notifying another staff member, the resident remained in bed without care for several hours. Witness statements revealed that the resident was not assisted out of bed until late morning, by which time they were soaked in urine and visibly upset. The resident's breakfast was left uneaten, and when they were finally brought to the dining table, they were only given a portion of fruit instead of a full meal. Staff members reported that the resident appeared sad and emotional due to the neglectful care they received. The facility's administration was informed of the situation, but initial actions were insufficient to address the neglect. The administrator later acknowledged that the incident should have been investigated more thoroughly at the time it occurred. The failure to provide timely incontinence care and an adequate meal resulted in emotional distress and a diminished quality of life for the resident.
Failure to Timely Report Alleged Neglect
Penalty
Summary
The facility failed to report allegations of potential abuse and/or neglect to the State Survey Agency within the required two-hour window, as mandated by state law. This deficiency involved a long-term resident who had recently moved to the nursing facility portion due to increased medical and physical needs. The resident had a history of moderate intellectual disability, schizoaffective disorder, and bipolar disorder with severe manic episodes and psychotic symptoms. On the morning of June 7, 2024, three Nursing Assistants alleged that the resident had been neglected by a lead Nursing Assistant. These concerns were communicated to a Registered Nurse Case Manager and subsequently to the Developmental Disability Administrator by lunchtime. However, the facility did not report the neglect allegation to the State Agency until later that evening, well beyond the two-hour reporting requirement. Interviews with the involved staff revealed a lack of awareness regarding the necessity to report such allegations within the specified timeframe. Staff members believed that others would report the incident, indicating a breakdown in communication and understanding of the reporting protocol. This delay in reporting placed residents at risk for abuse and/or neglect.
Delayed Investigation into Alleged Neglect
Penalty
Summary
The facility failed to conduct a timely and thorough investigation into allegations of neglect involving two residents. Resident 1, who had a history of moderate intellectual disability, schizoaffective disorder, and bipolar disorder, was largely wheelchair-bound and dependent on staff for care. Resident 2, diagnosed with Down Syndrome, Alzheimer's Disease, and Spastic Cerebral Palsy, was also wheelchair-bound and reliant on staff. On June 7, 2024, concerns about possible neglect of Resident 1 were reported by Nursing Assistants to a Registered Nurse Case Manager, who then informed the Developmental Disability Administrator. However, the Administrator only spoke to the alleged perpetrator, an Assistant Lead Nursing Assistant, and did not take further action to protect Resident 1 or investigate the report until June 10, 2024. During this period, the alleged perpetrator continued to work with both residents, and no protective measures were implemented. It was not until June 10, 2024, that the incident was reported again by a Lead Nursing Assistant, who also expressed concerns about possible neglect of Resident 2. The facility's Administrator acknowledged that the investigation did not begin until three days after the initial report and that the alleged perpetrator was not removed from resident care until June 11, 2024. This delay in response and failure to protect the residents placed them at risk for diminished quality of life and continued possible neglect.
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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 Medical Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cheney Care Center | 10.1 mi | — | 0 | 0 |
| North Central Care Center | 13.7 mi | — | 0 | 0 |
| South Hill Rehabilitation And Care Center | 14.1 mi | — | 2 | 0 |
| Spokane Veterans Home | 14.2 mi | — | 1 | 0 |
| Rockwood South Hill | 14.7 mi | — | 1 | 0 |
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