Lakewood Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 24, 2023

  Based on interview and document review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 resident (R1) who was identified as at risk for elopement and left the facility with out staff knowledge for 10 hours and 45 minutes before it was discovered he was gone. This was an immediate jeopardy for R1. The immediate jeopardy began on 5/15/23, at 9:02 p.m., when R1 cut off his wander guard, left the facility unsupervised, in the evening. It was not identified until 5/16/23, at 7:45 a.m. that R1 was missing. At approximately 8:30 a.m. four blocks away from the facility R1 was located, despite being care planned for hourly checks. […]

• Actual harm, isolatedF689Sep 11, 2024

  Based on observation, interview, and document review, the facility failed to ensure fall interventions were implemented as care planned to prevent falls for 1 of 4 residents (R19) reviewed for falls. This resulted in actual harm to R19 who's fall resulted in a humerus (a long bone in the arm that runs from the shoulder to the elbow) fracture. Findings include: R19's Therapy Eval and Re-Eval note dated 12/13/23 at 11:30 a.m., identified R19 was a high fall risk. R19 had difficulty following directions and was able to ambulate with contact guard assist (CGA) (a term used in physical therapy and occupational therapy to describe a level of assistance provided to a resident. […]

• No harm, potential for more than minimal, widespreadF812Aug 26, 2026

  Based on observation, interview and document review, the facility failed to ensure the sanitary/safe conditions by labeling leftovers stored in walk-in freezer. This had the potential to affect all 29 residents receiving meals from the kitchen. Findings include: An initial tour of the kitchen was conducted on 8/24/26 at 11:20 a.m., with the dietary manager (DM). During the walk-through of the walk-in freezer there were six 1-quart zip lock bags full of soup, lying flat on a sheet pan with the label of Wisc Cheese but the packages did not have a date it was prepared. There was also a rectangle bin under the sheet pan and was full of 1-quart zip lock bags. […]

• No harm, potential for more than minimal, widespreadF801Jun 26, 2025

  Based on interview and document review, the facility failed ensure a certified and credentialed dietary manager oversaw and supervised food preparation and services of the kitchens. This had the potential to affect all 25 residents, visitors and staff who consumed food from the kitchen. Findings include: On 6/23/25, at 12:19 p.m. cook (CK)-A stated the dietary manager (DM)-B oversaw the kitchen's day to day operations and was the team lead and the facility social worker (SW)-A was the managers supervisor. CK-A stated the facility's dietician came to the facility monthly. During interview on 6/24/25, at 2:31 p.m. […]

• No harm, potential for more than minimal, widespreadF812Aug 18, 2022

  Based on observation, interview and document review the facility failed to ensure the dishawasher tempuratures met the minumum tempuratures to ensure adequate sanitization to prevent food born illness. This had the potential to affect all 24 residents currently residing in the facility. Findings include: On 8/17/22, at 11:46 a.m. dietary aide (DA)-A was observed washing dishes via the facility's [NAME] brand, high temperature dish washer. The thermometer on the wash cycle registered 144 degrees Fahrenheit (F), the rinse cycle temperature registered 167 degrees F. DA-A verified the final rinse temperature registered 167 degrees. The machine utilized hot water sanitization and automatically dispensed the dishwashing detergent and rinse chemical. […]