Lakewood Health System

In the surveyor’s words

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

• Actual harm, isolatedF684Jul 17, 2024

  Based on interview and document review, the facility failed to ensure adequate supervision to prevent wandering to unsafe places and falls for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm to R1 when she fell and sustained a fracture to the right leg. The facility implemented corrective action so the deficient practice was issued at past non-compliance. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], identified R1 required supervision with eating, oral hygiene, toileting, and shower/bathing, partial to moderate assistance personal hygiene, roll left to right, sit to lying, lying to sitting, and toilet transfers. Substantial to maximum assistance to transfer from chair to bed and sit to stand machine. […]

• No harm, potential for more than minimal, widespreadF812Jun 29, 2022

  Based on observation, interview, and document review, the facility failed to ensure food items were properly stored and dated in 1 of 1 kitchens and 2 of 2 kitchenettes in the facility to prevent food borne illness. This deficient practice had the potential to affect 73 of 74 residents who were served food from the main kitchen and kitchenettes. Findings include: During the initial kitchen tour with the baker-cook (BC) on 6/26/22, at 1:40 p.m. the following observations were made: The walk-in refrigerator storing milk and dairy products was noted to have: A crate containing approximately five half pint non-fat milk cartons with a use-by-date of 6/18/22, and approximately 15 cartons with a use-by-date of 6/20/22. […]

• No harm, potential for more than minimal, widespreadF814Jun 29, 2022

  Based on observation and interview, the facility failed to ensure proper containment of garbage in the outside dumpsters to prevent harboring pests and rodents. This had the potential to affect all 74 residents residing in the facility. Findings include: On 6/28/22, at 10:20 a.m. during the kitchen sanitation tour, the facility's two outside dumpsters were observed located at the end of the back parking lot next to an area of vegetation and wildlife. The dumpster on the left had one lid open, exposing the interior of the dumpster. The Dietary Manager (DM) stated at the time the dumpsters were used for recycling. DM stated housekeeping staff disposed of dietary's refuse, such as cardboard boxes from food deliveries, into the dumpsters. On 6/29/22, at 9:50 a.m. […]

• No harm, potential for more than minimal, patternF576Nov 8, 2023

  Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 5 of 5 residents (R2, R40, R46,R49, R27) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 74 residents residing in the facility. Findings include: During a resident council meeting on 11/7/23 at 2:02 p.m., five residents attended. All five residents, R2, R40, R46, R49, R27, confirmed mail was not delivered on Saturdays at the facility, and they had to wait until Monday to receive their mail. During an interview on 11/7/23 at 3:09 p.m., activity assistant (AA)-A indicated activity staff delivered mail to residents. […]

• No harm, potential for more than minimal, patternF585Nov 8, 2023

  Based on observation, interview and document review, the facility failed to ensure grievance procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired, for 5 of 5 residents (R2, R40, R46, R49, R27) reviewed for grievances. This deficient practice had the potential to affect all 74 residents residing in the facility. Findings include: During a resident council meeting on 11/7/23 at 2:02 p.m., five residents attended. All five residents, R2, R40, R46, R49, R27, confirmed they were not aware of how to file a grievance at the facility. […]