Lakewood A Continuing Care Center

In the surveyor’s words

From the most serious findings on record at Lakewood A Continuing Care Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Dec 11, 2025

  Based on interviews, the facility failed to ensure the Food Service Director (FSD) met the qualifications of a Certified Food Service Director. This had the potential to affect all the residents. Finding:On 12/9/25 at 9:16 a.m., during an interview with a surveyor, the FSD stated that she has been in this role for about ten months. She stated that she does not have the qualifications for the job and that she is currently not enrolled in any qualifying course or a Managerial Serve Safe course. She then stated the facility's dietician is on a consultant basis and comes in monthly. […]

• No harm, potential for more than minimal, patternF584Dec 11, 2025

  Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units (Skilled, Moonlight Bay and Long-Term Care) and a common area for 1 of 1 facility tour. Findings:On 12/10/2025 from 10:10 a.m. to 10:40 a.m., an Environmental Tour was conducted with a Maintenance worker and the Administrator in which the following findings were observed: Common area - The main lobby area, near the lobby desk and door to the outdoors, had cracked and lifted linoleum creating an uncleanable surface. […]

• No harm, potential for more than minimal, patternF657Dec 11, 2025

  Based on observation, record reviews, and interviews, the facility failed to develop a Comprehensive Care Plan that addressed the physical needs of 4 of 22 sampled residents (Resident #9 [R9], R2, R60 and R7).1. R9 was admitted in June 2024 with diagnoses to include chronic pain and bilateral hand and knee contractures. A review of R9's care plan, most recently revised on 10/22/25 states, The resident is (SPECIFY High, Moderate, Low) risk for falls r/t [related to] Gait/balance problems. and lacked evidence that the care plan was accurately revised to reflect R9's current fall risk status. Further review of the care plan indicated a focus of .acute on chronic pain as it relates to my fibromyalgia, contractures, and functional deficits. […]

• No harm, potential for more than minimal, patternF684Dec 11, 2025

  Based on record reviews and interviews, the facility failed to ensure physician orders were followed for a physical therapy evaluation for 1 of 3 residents reviewed for positioning and mobility, for diet orders for 1 of 4 residents reviewed and for medication orders for 1 of 4 sampled residents reviewed (Resident #9 [R9] R60, R56 and R10).Findings: 1.R9 has diagnoses to include hemiplegia, muscle spasticity, and bilateral hand and knee contractures. A review of R9's provider progress note dated 9/26/25 states, .consult for spasticity.the patient is seated in [his/her] wheelchair leaning to the right. […]

• No harm, potential for more than minimal, patternF842Dec 11, 2025

  Based on observation, record reviews, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 2 sampled residents reviewed for Activities of Daily Living (Resident #49 [R49], R41) and 1 of 3 residents observed for medication administration (R52).Findings:1. A review of R49's care plan indicates he/she .has an ADL [activities of daily living] self-care performance deficit r/t [related to] Hemiplegia.often lethargic on bath days.Notify nurse and perform full bed bath instead.A review of R49's bathing task documentation in the Electronic Medical Record (EMR) indicates whirlpool or shower and document every Wednesday day shift and prn [as needed]. […]