The Oaks at Lakewood

Inspectors wroteBased on interview and record review, the facility failed to ensure substantial injuries/injuries of unknown sources were reported to the State Agency Reporting Hotline for 2 of 3 sampled residents (Residents 7 and 9) when reviewed for abuse. This failure placed residents at risk for potential abuse/neglect and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 2 of 18 sampled residents (Residents 11 and 5) when reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required nursing staff posting accurately reflected the actual staff numbers and actual hours worked for 5 of 7 sampled days (01/22/2026, 01/23/2026, 01/24/2026, 01/25/2026 and 01/26/2026) when reviewed for sufficient staffing. This failure caused the facility's staffing information to not be readily available to residents, and prevented the residents, family members and visitors from knowing the facility's actual number of available nursing staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement transmission-based precautions (TBP) for 1 of 4 residents (Resident 4) reviewed for TBP, and failed to use gloves when administering an injectable medication for 1 of 4 sampled residents (Resident 54) reviewed for medication administration. This failure placed residents and staff at risk for communicable diseases, poor clinical outcomes, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment during meal service for 1 or 3 sampled wings (North wing) when reviewed for dinning. This failure placed residents at risk for decreased appetite and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS, an assessment tool) accurately reflected the status for 2 of 18 sampled residents (Residents 54 and 17) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer a timely care conference to 1 of 3 sampled residents (Resident 36) and failed to revise a plan of care for 1 of 3 sampled residents (Resident 60) when reviewed for care plan revision. This failure placed residents at risk of not having input into their plan of care, inaccurate plans of care, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary assistance with activities of daily living (ADLs) for 1 of 2 sampled dependent residents (Resident 4) reviewed for ADL care. This failure placed the resident at risk for poor nutrition, weight loss, and a diminished quality of life. Findings Included . Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure, dementia ( loss of memory, language, problem-solving and other thinking abilities) and severe malnutrition (condition when someone doesn't have enough nutrients to meet their needs). The admission Minimum Data Set (MDS) an assessment tool, dated 05/13/2024, showed Resident 4 was usually able to understand others. Observation on 10/17/2024 at 9:42 AM, showed Resident 4 lying in bed, they appeared very frail and weak. [...]

Inspectors wroteResident 54 Review of the facility policy about Injections, Insulin administration dated 06/01/2023, showed Cleanse injection site with alcohol if necessary. Resident 54 was admitted to the facility on [DATE] with diagnoses that included heart failure and diabetes. The quarterly Minimum Data Set (MDS), an assessment tool, dated 09/25/2024, showed Resident 4 was able to make needs known. During an observation of medication administration on 10/21/2024 at 10:44 AM, Staff E, Licensed Practical Nurse (LPN) followed by Staff F, LPN administered 2 different insulins to different areas on Resident 54's abdominal wall without cleaning the skin area. In addition, the nurse did not wear gloves. During an interview on 10/21/2024 at 10:50 AM, when asked about injection practices, Staff E, LPN, stated they usually use alcohol wipes prior to administration. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received necessary treatment/services to prevent new ulcers for 1 of 3 sampled residents (Resident 7) reviewed for pressure ulcers. This failure placed the resident at risk for decreased comfort, infection, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe environment was maintained related to facility equipment for 1 of 4 sampled residents (Resident 14) reviewed for accident hazards. This failure placed the resident at risk for avoidable injuries and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 sampled residents (Resident 54) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain medications were provided as the provider ordered for 1 of 2 sampled residents (Resident 69) reviewed for pain management. This failure placed the resident at risk of receiving incorrect pain medication, sedation, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 1 sampled resident (Resident 125) received medications as ordered when out of the building for dialysis (a process of removing waste from the blood) when reviewed for dialysis. This failure placed the resident at risk of reduced medication effectiveness, increased pain, increased depression, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure expired eye drops were removed timely from use in 1 of 3 medication carts (Red Wood) reviewed for medication storage. This failure placed the residents at risk for receiving expired medications, ineffective medications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to schedule a dental appointment for 1 of 3 sampled residents (Resident 53) reviewed for dental services. This failure placed the resident at risk for unmet dental needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to schedule a dental appointment for 1 of 3 sampled residents (Resident 54) reviewed for dental services. This failure placed the resident at risk for unmet dental needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed-hold notice, at the time of transfer to the hospital, for 3 of 4 residents (Residents 22, 55 and 67) reviewed for hospitalization. This failure placed the residents at risk for a lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to provide services to improve hearing for 2 of 3 residents (Residents 13 and 33) reviewed for communication/sensory. This failure placed residents at risk of not being able to communicate, inability to participate in activities, feelings of isolation, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement in a manner that residents understood for 3 of 3 residents (Residents 13, 24 and 11) reviewed for arbitration agreement. This failure placed residents at risk of forfeiting their right to a trial without consent, lack of adequate resolution of violations of rights, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a timely and thorough investigation to rule out abuse or neglect for 1 of 2 resident (Resident 67) reviewed for abuse, accidents and/or incidents. The facility failed to conduct a timely and thorough investigation on an allegation of abuse/neglect for Residents 67 related to percutaneous endoscopic gastrostomy tube (PEG, a feeding tube placed through the skin and stomach wall to aid in deliver of nutrition) dislodgement. This failure to conduct a timely and thorough investigation placed the residents at risk for unidentified abuse and/or neglect and continued exposure to abuse and/or neglect.

Inspectors wroteResident 55 During an interview and observation on 12/02/2023 at 11:30 AM, Resident 55 stated repeatedly that they could not hear the questions asked. When asked about use of a hearing aid Resident 55 stated I haven't had my hearing aids since I came to this facility, but it would be nice to have a new pair. Review of the MDS dated [DATE] showed that Resident 55 admitted to the facility on [DATE] and was able to make needs known. It further showed that Resident 55 had Adequate, hearing and that no hearing aid appliance was used. Review of the quarterly MDS dated [DATE] showed that Resident 55 had Adequate, hearing and that a hearing aid appliance was used. During an interview on 12/06/2023 at 11:05 AM, Staff F, MDSC, stated that both the annual and quarterly MDS needed to be modified/corrected. [...]

Inspectors wroteResident 61 Review of Resident 61's medical diagnosis list showed that the resident had a diagnosis of depression and anxiety classified on admission date 03/30/2021. Review of Resident 61's PASRR, dated 11/10/2023, completed by the hospital prior to Resident 61's admission to the facility on [DATE], showed no mental disorders indicated on the form. Review of the physician orders on 12/06/2023 showed that Resident 61 was prescribed duloxetine (antidepressant medication) related to depression to be provided twice a day. During an interview on 12/07/2023 at 12:16 PM, Staff C, SSS, stated that the admission PASSAR was inaccurate and a new one should have been completed upon admission. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan that addressed the use of adaptive equipment for hearing for 1 of 32 residents (Resident 55) whose care plans were reviewed. This failure placed the resident at risk for communication difficulty and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure physician orders were followed for 1 of 5 residents (Resident 61) reviewed for unnecessary medication. This failure placed the resident at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 1 of 5 residents (Resident 128) reviewed for ADLs. This failure placed the resident at risk for unmet needs, poor hygiene, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that there was an adequate system in place to communicate with the dialysis center for 1 of 1 resident (Resident 127) reviewed for dialysis. This failure placed the resident at risk for adverse health outcomes, inadequate quality of care and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility's arbitration agreement failed to specify selection of a venue convenient to both parties. This failure placed residents at risk of not being able to resolve arbitration and a diminished quality of life.