Ahc of Lakewood, LLC

In the surveyor’s words

From the most serious findings on record at Ahc of Lakewood, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF838Dec 21, 2023

  Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included the use of an electronic elopement prevention system, dialysis services and hospice services. Findings include: I. Record review The facility assessment was provided by the nursing home administrator (NHA) on 12/19/23 at 11:27 a.m. The facility assessment was last reviewed on 10/17/23 by the NHA, director of nurses (DON) and the interdisciplinary team (IDT). […]

• No harm, potential for more than minimal, patternF730Dec 21, 2023

  Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews for three of five certified nurse aides (CNAs) reviewed. Specifically, the facility had not provided inservice education based on the outcome of the performance reviews for CNA #1, #2 and #4. Findings include: I. Record review CNA #1 (hired 8/10/22) had a performance review on 11/10/23. CNA #2 (hired 8/10/22) had a performance review on 11/11/23. CNA #4 (hired 8/10/22) had a performance review on 8/10/23. -The CNAs did not have an inservice education plan based on the outcome of the review. II. […]

• No harm, potential for more than minimal, isolatedF684Mar 19, 2026

  Based on record review and interviews the facility failed to ensure one (#8) of five residents received treatment and care in accordance with professional standards of practice out of 35 sample residents.Specifically, the facility failed to:-Ensure Resident #8's blood sugar levels were being monitored consistently per physician's orders; and,-Ensure the physician was notified, per physician's orders, when Resident #8's blood sugar levels were out of range.Findings include:I. Facility policy and procedureThe Blood Glucose Testing policy and procedure, dated 9/11/23, was provided by the nursing home administrator (NHA) on 3/23/26 at 12:53 p.m. The policy read in pertinent part, Blood glucose testing will be performed by a licensed nurse or nursing assistant per physician order. […]

• No harm, potential for more than minimal, isolatedF759Mar 19, 2026

  Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%).Specifically the facility's medication error rate was 6.5%, or three errors out of 31 opportunities.Findings include:I. Facility policy and procedureThe Administration of Medication policy and procedure, dated 5/5/26, was provided by the nursing home administrator (NHA) on 3/23/26 at 12:53 p.m. The policy read in pertinent part, Licensed personnel, in accordance with professional standards of practice, will appropriately administer prescribed medications. Compare the prescription label to the order on the electronic medication administration record (eMAR). […]

• No harm, potential for more than minimal, isolatedF842Mar 19, 2026

  Based on observations, record review and interviews, the facility failed to maintain accurately documented medical records for one (#45) of two residents reviewed out of 35 sample residents.Specifically, the facility failed to ensure the administration of Resident #45's as needed (PRN) hydromorphone (opioid analgesic used to treat moderate-to-severe pain when other options are inadequate) on 3/12/26 and 3/13/26 was documented in the resident's electronic medication administration record (eMAR).Findings include:I. Facility policy and procedureThe Administration of Medication policy, updated 5/5/25, was provided by the nursing home administrator (NHA) on 3/23/26 at 1:59 p.m. […]