F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to ensure that a beard restraint was
worn by an employee during food preparation. This failure had the potential to cause foodborne illness in
the facility.
Finding:
An observation of the kitchen's tray line (a task for staff to prepare food for serving to residents) was
conducted on 5/18/22 at 12:59 P.M. The dietary aide (DA)1, who had a full beard, was adding food to the
trays and was not wearing a beard restraint (covers facial hair).
An interview was conducted with the Dietary Services Supervisor (DSS) on 5/18/22 at 1:04 P.M. The DSS
stated, We are out of them (beard restraints); not wearing one can cause hair to fall in the food.
An interview was conducted with the Director of Nursing (DON) on 5/19/22 at 10 A.M. The DON stated, It is
an Infection Control issue.
A review of the facility's policy titled, Employee Sanitary Practices, dated 2017, indicated, Policy: All
nutrition and food service employees will practice good personal hygiene and safe food handling practices
.Procedure: All employees will: 1. wear hair restraints (hair net,hat and/or beard restraint to prevent hair
from contacting exposed food .
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
555887
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555887
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakeside Special Care Center
11962 Woodside Avenue
Lakeside, CA 92040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to meet the minimum requirement of 80 square
feet (sq. ft.) per resident, for 26 of 27 resident rooms.
This failure had the potential to affect resident's health, safety, quality of care, or quality of life.
Findings:
During 5/16/22 through 5/19/22, 27 resident rooms were observed. All rooms were neat and clutter free.
Throughout the survey, residents were interviewed, both individually and during a group interview, and
residents' voiced no complaints related to privacy, the environment, or their shared rooms.
A review of the facility's Client Accommodation Analysis indicated there were 27 resident rooms and 26
rooms did not meet the minimum room size requirement.
There were 7 rooms in Cottage 1:
room [ROOM NUMBER], had 3 resident occupancy, 72 sq. ft. per resident, totaling 216 sq. ft.
room [ROOM NUMBER], had 3 resident occupancy, 72 sq. ft. per resident, totaling 216 sq. ft.
room [ROOM NUMBER], had 3 resident occupancy, 72 sq. ft. per resident, totaling 216 sq. ft.
room [ROOM NUMBER], had 3 resident occupancy, 74 sq. ft. per resident, totaling 222 sq. ft.
room [ROOM NUMBER], had 3 resident occupancy, 74 sq. ft. per resident, totaling 222 sq. ft.
room [ROOM NUMBER], had 3 resident occupancy, 72 sq. ft. per resident, totaling 216 sq. ft.
room [ROOM NUMBER], had 3 resident occupancy, 72 sq. ft. per resident, totaling 216 sq. ft.
There were 12 rooms (201-212) in Cottage 2. All the rooms had 4 resident occupancy, 70.4 sq. ft. per
resident, totaling 281.75 sq. ft.
There were 7 rooms in Cottage 3:
room [ROOM NUMBER], had 3 resident occupancy, 72 sq. ft. per resident, totaling 216 sq. ft.
room [ROOM NUMBER], had 3 resident occupancy, 72 sq. ft. per resident, totaling 216 sq. ft.
room [ROOM NUMBER], had 3 resident occupancy, 72 sq. ft. per resident, totaling 216 sq. ft.
room [ROOM NUMBER], had 3 resident occupancy, 73 sq. ft. per resident, totaling 219 sq. ft.
room [ROOM NUMBER], had 3 resident occupancy, 73 sq. ft. per resident, totaling 219 sq. ft.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555887
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555887
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakeside Special Care Center
11962 Woodside Avenue
Lakeside, CA 92040
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
room [ROOM NUMBER], had 4 resident occupancy, 74.5 sq. ft. per resident, totaling 298 sq. ft.
Level of Harm - Potential for
minimal harm
room [ROOM NUMBER], had 4 resident occupancy, 74.5 sq. ft. per resident, totaling 298 sq. ft.
room [ROOM NUMBER], had 2 resident occupancy, 98 sq. ft. per resident, totaling 219 sq. ft.
Residents Affected - Some
The variations in room size requirement did not adversely affect the resident's health, safety, quality of care,
or quality of life during the survey.
Continuance of the room size waiver for all affected rooms was recommended.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555887
If continuation sheet
Page 3 of 3
