Lakewood Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF880Jul 27, 2021

  Based on observation, interview, and record review, the facility failed to implement infection control interventions in the yellow zone (unit for residents suspected Corona Virus [COVID-19] a highly contagious virus that causes severe respiratory illness that affects the lungs and airways) to prevent and control the spread of COVID-19 for eight of eight residents (Residents 3, 23, 195, 216, 222, 224, 241, and 490) in the facility in accordance with the facility's infection control policies and procedures (P/P) and mitigation plan ([MP] a plan to reduce the spread of the COVID-19 virus) by failing to: 1. Ensure Licensed Vocational Nurse 7 (LVN 7) and Certified Nurse Assistant 1 (CNA 1) removed their gown after caring for Resident 490 and prior to caring for Residents 3 and 224. 2. […]

• Immediate jeopardy, isolatedF689Jun 13, 2025

  Based on observation, interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 1) who was confused with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), anxiety (a feeling of fear, dread, and uneasiness), hypertension (high blood pressure), and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), did not elope (leave the facility unsupervised) from the facility on 6/8/2025 by failing to: 1). […]

• Immediate jeopardy, isolatedF689Jul 12, 2021

  Based on observation, interview, and record review, the facility failed to supervise and prevent one of 13 sampled residents (Resident 1), who had a history of elopement (resident who is cognitively, physically, mentally, emotionally and/or chemically impaired wanders away, walks away, runs away, escapes or otherwise leaves a facility) attempts, from eloping in accordance with the facility's policy and procedure, and the care plan for monitoring of Resident 1's whereabouts. This deficient practice resulted in Resident 1's elopement and placed Resident 1 at risk for serious injury or death from lack of access to medications, food and hydration, and exposure to accidents, as the whereabouts of Resident 1 are unknown. […]

• Actual harm, isolatedF688Dec 18, 2025

  Based on observation, interview, and record review, the facility failed to provide range of motion ([ROM] full movement potential of a joint) services to one of six sampled residents (Resident 6) with position and mobility (ability to move) concerns after experiencing femoral neck fractures (break in the bone just beneath the rounded bone of the hip) to both hips on 6/6/2025 by failing to: 1. Clarify Resident 6's weight-bearing tolerance ([WB tolerance] amount of weight allowed to put on an injured or surgically repaired limb) and ROM parameters (extent of movement at a joint) to both legs after Resident 6's orthopedic physician's (branch of medicine dealing with the correction or prevention of deformities, disorders, or injuries of the bones and associated soft tissue) appointment on… […]

• Actual harm, isolatedF689Dec 18, 2025

  Based on interview and record review, the facility failed to provide care and services to prevent a fall for four of 10 sampled residents (Resident 139, Resident 155, Resident 102, and Resident 164) when: 1. Certified Nursing Assistant (CNA) 4 failed to provide two-person assistance prior to providing care to Resident 139.2. CNA 4 failed to place the low-air-loss mattress (LALM, a specialized air mattress that constantly releases air to alternate pressure to shift weight) into static mode (no alternation in pressure), prior to providing care to Resident 139.3. Staff failed to apply a helmet to Resident 155 as ordered by her physician.4. Staff failed to ensure Resident 102 was adequately supervised while in possession of sharpened pencils.5. […]