Lakewood a Continuing Care Center

Inspectors wroteBased on interviews, the facility failed to ensure the Food Service Director (FSD) met the qualifications of a Certified Food Service Director. This had the potential to affect all the residents.

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units (Skilled, Moonlight Bay and Long-Term Care) and a common area for 1 of 1 facility tour.

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to develop a Comprehensive Care Plan that addressed the physical needs of 4 of 22 sampled residents (Resident #9 [R9], R2, R60 and R7).1. R9 was admitted in June 2024 with diagnoses to include chronic pain and bilateral hand and knee contractures. A review of R9's care plan, most recently revised on 10/22/25 states, The resident is (SPECIFY High, Moderate, Low) risk for falls r/t [related to] Gait/balance problems. and lacked evidence that the care plan was accurately revised to reflect R9's current fall risk status. Further review of the care plan indicated a focus of .acute on chronic pain as it relates to my fibromyalgia, contractures, and functional deficits. and interventions included, .Identify, record, and treat the resident's existing conditions which may increase pain.(SPECIFY: [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure physician orders were followed for a physical therapy evaluation for 1 of 3 residents reviewed for positioning and mobility, for diet orders for 1 of 4 residents reviewed and for medication orders for 1 of 4 sampled residents reviewed (Resident #9 [R9] R60, R56 and R10).

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 2 of 2 sampled residents reviewed for Activities of Daily Living (Resident #49 [R49], R41) and 1 of 3 residents observed for medication administration (R52).

Inspectors wroteBased on observations, interviews, record reviews, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection for 3 of the 4 days of survey (12/8/25, 12/9/25 and 12/11/25).1. On 12/8/25 at 1:47 p.m., during an interview with the Infection Preventionist (IP), a surveyor observed the following: Contact Precaution Signage was observed on the wall to left and right of room [ROOM NUMBER]. A Personal Protective Equipment (PPE) cart was observed to the left of the door containing masks, gowns, and gloves. A housekeeping cart was observed in the hallway outside the resident room. The IP stated that the Contact Precautions were for COVID. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were offered pneumococcal vaccinations in accordance with the Centers for Disease and Prevention Control (CDC) recommendations for 2 of 5 residents reviewed for immunizations (Resident #7 [R7] and R8). On 12/9/25, the Facility's Policy Pneumococcal Vaccine, revised 03/2025, was reviewed. The policy stated, 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility . 2. Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission. [...]

Inspectors wroteBased on record reviews and interview, the facility failed to perform adequate screening and documentation for the updated coronavirus (Covid-19) vaccine as required for 4 out of 5 residents screened for Covid-19 immunizations (Resident #7 [R7], R8, R71, and R85). On 12/10/25, from 9:20 - 10:00 a.m., during an interview with a surveyor and the Infection Preventionist (IP), the following was reviewed and confirmed:R7 was admitted on [DATE]. The clinical record lacks evidence that R7 was offered the updated COVID-19 vaccination or signed informed consent and/or declination for the updated Covid-19 immunization. R8 was admitted on [DATE]. The clinical record lacks evidence that R8 was offered the updated COVID-19 vaccination or signed informed consent and/or declination for the updated Covid-19 immunization. R71 was admitted on [DATE]. [...]

Inspectors wroteBased on Certified Nursing Assistant (CNA) employee education review and interview, the facility failed to implement and maintain an effective training program to ensure that a CNA attended the required 12 hours of annual in-service education training, and annual dementia training for 3 of 5 randomly selected CNAs reviewed on survey (CNA4. CNA-M3 and CNA-M4).

Inspectors wroteBased on observations and interviews the facility failed to promote care for residents in a manner that maintains each resident's dignity and respect when staff failed to serve all residents seated at the same table at the same time for 1 of 3 meals and observed staff standing while assisting residents with their lunch meal. (12/8/25)

Inspectors wroteBased on record reviews and interviews, the facility failed to issue a written transfer/discharge notice and a bed hold notice to include cost of care to the legal representative for 2 of 3 sampled resident reviewed for transfer to an acute care hospital. (Residents #82, #2 [R82, R2]).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's physician supervised and evaluated weight loss for 1 of 5 residents reviewed with potentially significant weight loss (Resident #7 [R7]). On 12/8/25, R7's clinical record was reviewed and revealed the following:-Review of documented weights indicated R7's weight on 10/29/25 was 119.8 pounds, R7's weight on 11/28/25 was 112.2 pounds, which is a -6.34% weight loss in 1 month.-Review of R7's brief interview for mental status dated 12/5/25, indicated R7 has moderate cognitive impairment. -Review of the Provider's Progress Note dated 12/5/25 indicated R7 denied weight loss. The progress note lacked evidence that the potentially significant weight loss was identified or addressed. [...]

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, for 2 of 6 Controlled Substances Books reviewed (Long Term Care House 5/6 [LTC House 5/6] and LTC House 7/8 Medication Tech med cart books).

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use for 1 of 2 medication storage rooms observed (Long Term Care [LTC] House med storage room).

Inspectors wroteBased on observation, interview and the facility's Food Storage, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for a dish machine, metal shelving and the floor; and failed to ensure foods were sealed, labeled, dated and/or discarded if past use by date in a walk-in refrigerator for 1 of 1 kitchen tours. (12/8/25)

Inspectors wroteBased on interviews and record review, the facility failed to provide specialized rehabilitative services or obtain the required services from an outside resource that is a provider of specialized rehabilitative services for 1 of 1 residents reviewed for rehabilitative services (Resident #7 [R7]). [...]

Inspectors wroteBased on observations and interview, the facility failed to post in a place accessible to all residents, family members and legal representatives, the results of the most recent surveys for 4 of 4 survey days.

Inspectors wroteBased on observations and interview, the facility failed to post the nurse staffing information in a predominant place, readily accessible and visible to all residents in 3 of 4 areas of the facility for 4 of 4 survey days.

Inspectors wroteBased on the review of annual evaluations and interviews, the facility failed to complete annual performance evaluations for Certified Nursing Assistants - Medication Aide (CNA-M) at least every 12 months, for 3 of 5 personnel files reviewed with employment greater than 1 year. (CNA#4, CNA-M3, CNA-M4)

Inspectors wroteBased on review of the facility Reportable Incident Form, record review and interviews, the facility failed to notify timely the Medical Provider of an unwitnessed fall with head injury for 1 of 3 residents reviewed who sustained a head injury from a fall (Resident #1 [R1]). On 11/18/25, the facility's Reportable Incident Form that was sent to Licensing and Certification, dated 11/10/25, was reviewed. Documentation on the form indicated that on 11/7/25 at approximately 11:00 p.m., R1 had an unwitnessed fall in his/her room. From the fall, R1 sustained an injury to the left forehead, a black eye on the right periorbital, a skin tear to the right upper lip and a skin tear to the left wrist. A review of the clinical record indicated that on 11/7/25 the Charge Nurse/Registered Nurse (RN1) who assessed R1 after the fall filled out a Risk Management Form. [...]

Inspectors wroteBased on the Reportable Incident Form, the facility policy and procedure for reporting and interviews, the facility failed to notify the State Agency (Division of Licensing and Certification) of an unwitnessed fall with head injury for 1 of 3 residents reviewed that sustained a head injury from a fall. On 11/18/25, the facility's Reportable Incident Form that was sent to Licensing and Certification, dated 11/10/25, was reviewed. Documentation on the form indicated that on 11/7/25 at approximately 11:00 p.m., R1 had an unwitnessed fall in his/her room. From the fall, R1 sustained an injury to the left forehead, a black eye on the right periorbital, a skin tear to the right upper lip and a skin tear to the left wrist. A review of the facility's reporting a fall with injury policy and procedure indicated under Section: To state and federal agencies: [...]

Inspectors wroteBased on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units (the Skilled Unit, the Long-Term Care Unit and the Memory Care Unit) for 1 of 1 facility tour.

Inspectors wroteBased on the facility's policy, record review, and interview, the facility failed to notify the State Agency after an allegation of potential neglect concerns were identified, failed to investigate an unwitnessed fall resulting in a major injury, and failed to ensure that the facility's investigation was sent to the State Agency within 5 business days of the incident for 2 of 4 complaint investigations reviewed during an annual survey.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure that physician orders were followed for 1 of 2 Resident's reviewed for oxygen. (Resident #3) Additionally, the facility failed to follow recommendations given by Physical Therapy (PT) for 1 of 1 residents reviewed for restorative care (Resident #87).

Inspectors wroteBased on observations and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 5 of 5 residents reviewed for respiratory care (Resident # 5, #23, #49, #3, #13).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to properly store medications and biologicals in medication refrigerators, treatment carts and medication carts for 3 out of 3 units surveyed for medication storage.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for fans, ceiling vents, and ceiling lights and failed to ensure that the kitchen ice machine and the skilled unit ice machine were plumbed in accordance with code requirements to prevent food contamination for 2 of 2 tours.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that a resident's choice in the area of bathing and hygiene were being followed for 1 of 20 sampled residents (Resident #37).

Inspectors wroteBased on a review of the Nursing Facility Reportable Incident submitted to the Division of Licensing and Certification on 10/21/24, the facility's internal investigation, written statements by staff, facility policy, clinical record review and interviews, the facility failed to protect a resident's right to be free from physical and emotional abuse by staff when a Certified Nursing Assistant (CNA #1) forcibly dressed and transferred a resident. (Resident #70)

Inspectors wroteBased on observation, interview, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured for 2 of 2 observations for 2 of 3 days of survey. (11/12/24 and 11/13/24)

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside on the Long Term Care Unit. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL)'s. (Resident #4, #45, and #87).

Inspectors wroteBased on observations and interviews, the facility failed to follow appropriate infection control procedures related to hand hygiene during 1 of 2 medication pass observations. Review of Policy/Procedure #31-202, Hand Hygiene Program for Northern Light Member Organizations that Provide Clinical Patient Care, states, .Hand Hygiene is to occur: 1. Before touching a patient .The use of gloves does not replace Hand Hygiene .Hand Hygiene shall occur prior to donning gloves and after doffing gloves . During a medication pass observation on the Memory Lane unit on 11/14/24 between 11:30 a.m. and 11:38 a.m., Registered Nurse (RN) #2 was observed in room [ROOM NUMBER], checking Resident #61's blood sugar, with gloved hands. RN #2 was observed exiting room [ROOM NUMBER] with gloved hands and walking to the medication cart located outside of room [ROOM NUMBER]. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure that a call bell was functional for 1 of 20 sampled residents (#37). Finding; On 11/12/24 at 9:10 a.m. during an interview, Resident #37 stated his/her call bell has not been working and they said they fixed it. At this time, the surveyor pushed the call bell, the light above the door did not illuminate. The surveyor then went to the nurse's station and checked the call bell screen and asked the Registered Nurse (RN#3) if the call bell screen shows active call bells. RN#3 stated if it's highlighted red is an active call bell. Resident #37's room had no indication of the call bell being activated. Both the Surveyor and RN #3 went to resident #37's room. A Certified Nurses Aid also entered the room and stated the call bell was not working. [...]

Inspectors wroteBased on review of the quarterly Quality Assurance Committee meeting attendance sheets and interview, the facility failed to ensure that the Medical Director attended 3 of 3 quarterly meetings.

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 3 of 3 Units. (Skilled unit, Dementia unit and Long Term Care unit) for 2 of 2 environmental tours (08/29/23 and 8/31/23)

Inspectors wroteBased on record review and interview, the facility failed to ensure weekly pressure ulcer documentation were completed as per facility policy for 1 of 1 residents reviewed for pressure ulcers (Resident #68 [R68].

Inspectors wrote2. On 8/28/23 at 12:10 p.m. a surveyor observed R27 wearing oxygen that was being administered by a nasal cannula (NC) at a rate of 3 liters (L). On 8/28/23 R27's clinical record was reviewed and there was no evidence of a physician's order for the use of oxygen. A review of R27's nursing notes dated 6/19/23 to 7/11/23 shows documentation of R27 using oxygen daily at a rate of 3L per minute by nasal cannula. R27's clinical record review shows documentation that on 7/7/23 R27 transitioned from skilled care to long term care, the facility continued to monitor his/her use of oxygen daily until 7/11/23 (4 days after skilled services ended). R27's clinical record lacked evidence that R27's had a physician's order for the use of oxygen. A surveyor observed the oxygen concentrator and the vents located on the back of the machine were covered in dust. On 8/29/23 at 9:25 a.m. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure that portable oxygen was available for 1 of 1 resident (Resident #1 [R1]) to leave their room for activities and to eat in the dining room for breakfast, lunch and supper for 4 of 6 meals served (8/27/23 supper, 8/28/23 breakfast, 8/28/23 lunch, and 8/28/23 supper).

Inspectors wroteBased on observation and interviews, the facility failed to ensure that portable oxygen was available for 1 of 1 resident (Resident #1 [R1]) to leave their room to eat in the dining room for breakfast, lunch and dinner for 3 of 5 meals served (8/27/23 dinner, 8/28/23 breakfast, and 8/28/23 lunch).

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the resident and the resident's representative in writing of the transfers/discharges to an acute care hospital for 3 of 3 residents sampled for hospitalization ( Resident #53 [R53], Resident #15 [R15], and Resident #83 [R83]). In addition, the facility failed to notify the State Ombudsman of facility initiated transfer/discharges.

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 5 sampled residents admitted for skilled care services (Resident #27 [R27]).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that care plans were developed to reflect a resident's current needs for 2 of 19 residents reviewed (Resident #87 [R87] and Resident #27 [R27]).

Inspectors wroteBased on record review and interview, the facility failed to complete daily assessments and weekly or as needed dressing changes to a midline catheter for 1 of 1 sampled residents reviewed (Resident #53 [R53}).

Inspectors wroteBased on observations and interviews, the facility failed to ensure that the resident environment remained free from the potential risk of accidents, for 1 of 1 days of survey (8/28/23), when they failed to ensure a toilet was secured to the floor in a resident bathroom.

Inspectors wroteBased on record review and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 1 of 1 sampled resident reviewed with a current diagnosis of PTSD (Resident #27 [R27]).

Inspectors wroteBased on observations, interviews, the facility's Purchasing, Receiving, Storage, and Issuance of Food and Supplies Policy/Procedure #: FNS-4, and The facility's Sanitation, Infection Control, HACCP and Safety Policy/Procedure #: IC-FNS- 8, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for wall fans, a hanging pot rack, and hood filters; failed to ensure that staff with facial hair utilized beard restraints; and failed to ensure that food is stored, served and prepared in a safe, sanitary manner as evidenced by improper food storage in the walk-in freezer on 1 of 1 days of kitchen observations (8/28/23). In addition, the facility failed to monitoring for sanitizer solution levels in sanitizing buckets and failed to ensure that the dish machine was maintaining proper temperature ranges for proper cleaning and sanitizing. [...]

Inspectors wroteBased on observations, interviews, and the facility's Sanitation, Infection Control, HACCP, and Safety Policy/Procedure #: IC-FNS- 8, the facility failed to ensure that the kitchen high temperature dish machine was maintained in good repair and in safe operating condition for 4 of 4 dish machine observations (8/28/23, 8/29/23, 8/30/23 and 8/31/23) and failed to ensure proper cleaning and sanitizing of dishes for 1 of 4 kitchen tours (8/28/23).

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the resident and/or the resident's representative in writing of a bed hold notice for 3 of 3 residents sampled for hospitalization (Resident #53 [R53], Resident #15 [R15], and Resident #83 [R83]).

Inspectors wroteBased on interviews and observations, the facility failed to provide equipment (wheelchair) to maintain and/or improve residents' highest level of mobility for 1 of 1 resident reviewed for positioning and mobility (Resident #27).

Inspectors wroteBased on observations and interview, the facility failed to post the current daily nurse staffing information that included a separate breakdown of hours for each shift for registered nurses (RN's), licensed practical nurses (LPN's), and certified medical assistants (CNA's) for 3 of 4 survey days (8/28/23, 8/29/23, and 8/30/23). The facility also failed to port the current daily nurse staffing information for 1 of 4 survey days (8/30/23).