Lakewood Rehabilitation & Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 16, 2026

  Based on review of select facility policies, clinical records, facility-provided investigative documentation, observations, and staff interviews, it was determined the facility failed to ensure that one resident (Resident 1) was free from sexual abuse perpetrated by another resident (Resident 2). This failure placed one of eight residents sampled in Immediate Jeopardy to the health and safety of residents.Findings include: A review of the current facility policy entitled Abuse Prevention Program, last reviewed by the facility December 8, 2025, revealed the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. […]

• Immediate jeopardy, isolatedF689Jan 18, 2025

  Based on observations, review of clinical records, facility policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure adequate staff supervision and effective safety measures for a resident who expressed exit seeking behaviors and was identified as a wandering risk. The failure resulted in the elopement for one resident (Resident 1) out of 6 residents reviewed that were at risk for elopment. Following this elopement the facility further failed to promptly identify the resident's absence as well as identify supervisory and safety needs to prevent unsupervised exits from the facility, which placed residents in immediate jeopardy of unsupervised exits from the facility and the potential for serious bodily injury or death. […]

• Actual harm, isolatedF689Aug 30, 2024

  Based on a review of clinical records, select facility incident/accident reports, and staff interview it was determined the facility failed to timely implement effective safety interventions, including necessary staff supervision, at the level and frequency required, for a resident with known unsafe behaviors to prevent falls, including a fall with hip fracture for one resident out of the 24 sampled (Resident 91) and multiple falls for one out of the 24 sampled reviewed (Resident 33). […]

• Actual harm, isolatedF697Aug 30, 2024

  Based on a review of clinical records, observations, select facility policy, and staff, resident, and resident family interviews, it was determined the facility failed to implement pain management interventions and failed to recognize when the resident suffered pain without relief for one resident out of 24 sampled (Resident 260). Findings include: A review of the facility policy entitled Pain Assessment and Management, last reviewed by the facility on July 21, 2024, revealed the facility's pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. […]

• Actual harm, isolatedF600Jul 21, 2024

  Based on observation, a review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure that one resident (Resident A2) was free from verbal and mental abuse, which resulted emotional upset and mental anguish and failed to implement sufficient measures necessary to protect other residents from verbal and mental abuse perpetrated by one resident (Resident A1) out of 10 sampled residents. Findings include: Review of Resident A1's clinical record revealed admission to the facility on [DATE], with diagnoses, which included Alzheimer's disease, adjustment disorder with anxiety, and major depression. […]