Lake Woods Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lake Woods Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 12, 2023

  This citation refers to MI00139088. Based on observation, interview, and record review, the facility failed to prevent an elopement resulting in an immediate jeopardy when one Resident (R14) who was a known elopement risk, of three residents reviewed for elopement risk, was let outdoors by a staff member who did not know the resident. This deficient practice resulted in the elopement and potential for serious harm, injury, impairment, or death to R14 and all other residents assessed as an elopement risk. Findings include: The Immediate Jeopardy (a situation in which entity noncompliance has placed the health and safety of residents in its care at risk for serious injury, serious harm, serious impairment or death) began on 6/17/23 when R14 eloped from the facility. […]

• Actual harm, isolatedF686May 1, 2025

  Based on observation, interview and record review, the facility failed to prevent a pressure ulcer for 1 Resident (R26) of 2 Residents reviewed for pressure ulcers resulting in R26 developing a stage 3 pressure ulcer. Findings included: Review of R26 Admission Record dated 5/1/25 revealed he was [AGE] years old, admitted on [DATE] and had diagnoses that included: diabetes mellitus 2, abnormal posture, major depressive disorder, muscle weakness, muscle spasms, muscle wasting and atrophy, glaucoma, and dementia. He was his own responsible party. R26 was observed receiving a bed bath on 4/29/25 at 9:47 AM. R26's head was tilted to the left and he was unable to move his neck to an upright position. R26 was able to move his right hand and arm. […]

• Actual harm, isolatedF600Jun 12, 2024

  This Citation pertains to Intake Number MI00144963. Based on observation, interview, and record the facility failed to protect the resident's right to be free from physical abuse by a resident for one resident (Resident #2) of three residents reviewed for abuse and neglect, resulting in Resident #2 being pushed, fracturing her right radius and the right femoral neck after falling. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency on 05/31/24 revealed there was a resident to resident altercation occurred when (Name of R1) pushed (Name of R2) stating that she was in his way near the front lobby/dining room area. Resident have been separated and assessed by a licensed nurse to have no injury. There was no harm or psychosocial distress. […]

• Actual harm, isolatedF686May 20, 2024

  Based on observations, interview and record review, the facility failed to assess, monitor, implement pressure relief and treat for wounds and pressures ulcers for 3 Residents (R23, R37, R48,) of 4 resident reviewed for pressure ulcers, resulting in R37 developing an unstageable pressure ulcer on his back and a new pressure ulcer on his right thigh, R48's wound on her leg increasing in size and the pressure ulcer on her buttock worsening, and R23 missing wound treatments/assessments. […]

• No harm, potential for more than minimal, widespreadF908Jun 24, 2026

  Based on observation interviews and record review, the facility failed to maintain the kitchen exhaust system, potentially decreasing the system's ability to capture grease, smoke and particulate matter. Findings include:On 06/22/2026 at 8:58AM, observed the ventilation hood over the cookline in the main kitchen had three empty spaces that did not have a filter or spacer, and exposing the interior of the ductwork. During the observation, the Dietary [NAME] (DC) L was asked where the filters were and DC L answered they were stored on the cookline, next to cooking equipment, because they had fallen out of the tracks, of the hood, that the filters fit in. […]