O'Neill Healthcare Lakewood

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Aug 13, 2026

  Based on observation, interview, review of facility temperature monitoring logs, and facility policy, the facility failed to ensure unit refrigerators used for resident foods were maintained in a safe and sanitary manner. This had the potential to affect all residents receiving food by mouth. The facility identified one resident (#7) receiving nothing by mouth (NPO). The facility census was 88.Findings include:Observation on 08/12/26 at 3:55 P.M. with Mobile Director of Nursing (MDON) #392 of the first-floor resident refrigerator located across from the nurse's station revealed the following concerns:-an eight-ounce (oz) bottle of strawberry Neocate (a dairy free nutritional supplement) with an expiration date of 05/18/26-an eight oz bottle of vanilla Neocate with an expiration date of… […]

• No harm, potential for more than minimal, widespreadF812Aug 31, 2023

  Based on observation, staff interview, and policy review the facility failed to ensure food was labeled, dated, and stored appropriately. This had the potential to affect 91 of 91 residents who received meals from the facility kitchen. The facility identified five residents (#52, #70, #86, #87 and #202) who received no food by mouth. The facility census was 96. Findings include: The following concerns were noted during the main initial kitchen tour conducted on 08/28/23 between 8:16 A.M. […]

• No harm, potential for more than minimal, widespreadF921Aug 31, 2023

  Based on observation and staff interview the facility failed to ensure 15 residents (#5, #14, #21, #22, #31, #36, #51, #61, #67, #68, #69, #70, #79, #84, and #87) had a clean privacy curtain and failed to maintain clean and sanitary carpeting throughout the resident rooms and hallways. This had the potential to affect all 96 residents currently residing in the facility. Findings include: 1. Observation on 08/29/23 at 7:33 A.M. with State tested Nurse Assistants (STNAs) #887 and #900 verified Residents #5, #14, #21, #22, #31, #36, #51, #61, #67, #68, #69, #70, #79, #84 and #87 had privacy curtains that were stained and dirty. Interview on 08/29/23 at 7:36 A.M. […]

• No harm, potential for more than minimal, patternF692Aug 13, 2026

  Based on record review, interview, and review of the facility policy, the facility failed to ensure accurate and timely weights were obtained. This affected four (Residents #3, #36, #58, and #107) of four residents reviewed for nutrition. The facility census was 88.Findings include: 1. Review of the medical record revealed Resident #58 was admitted on [DATE] with diagnoses including diabetes, malnutrition, heart disease, schizophrenia, anxiety, cancer of the cecum, and acquired absence of other parts of the digestive tract. She was alert and oriented to person, place, and time (A&O x3). […]

• No harm, potential for more than minimal, isolatedF561Aug 13, 2026

  Based on record review, interviews, and facility policy review, the facility failed to honor Resident #15's preferences for showers. This affected one (Resident #15) out of eighteen sample residents. The facility census was 88.Findings include:Review of the medical record for Resident #15 revealed she was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, morbid obesity, peripheral vascular disease, hypertensive heart disease, anxiety disorder, cellulitis of right lower limb and buttock.Review of the provider orders dated 04/21/26 revealed Resident #15 was to receive showers as scheduled, and the nurse was to sign entry to verify personal care sheet was completed. […]