Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ahc Of Lakewood, Llc during CMS and state inspections, most recent first.
Missed Blood Sugar Monitoring and Failure to Notify Physician of High Glucose: Staff failed to consistently check a resident’s blood glucose as ordered and did not notify the physician when a reading was above the ordered threshold. The resident had diabetes with ketoacidosis and CKD, was cognitively intact, and had several missed or undocumented blood sugar checks. Staff also documented the resident as unavailable or refusing without further explanation, and there was no documentation that the physician was notified of the elevated glucose result.
Medication administration errors exceeded the allowed rate, with an LPN giving a lidocaine patch to a resident’s shoulder without an active order and initially giving only half of another resident’s ordered amlodipine dose. The DON stated nurses should have a physician’s order in the EMR before administering medication and that the LPN should have obtained an order before placing the patch on the shoulder.
Missing eMAR Documentation for PRN Hydromorphone: A resident with pain-related diagnoses and moderate cognitive impairment had PRN hydromorphone administrations recorded on the narcotic sheet but not in the eMAR. The resident said pain medication was not given timely after she requested it, while an LPN stated the doses were given and documented. The DON could not locate eMAR documentation for the narcotic administrations.
Missed Blood Sugar Monitoring and Failure to Notify Physician of High Glucose
Penalty
Summary
Facility staff failed to provide blood glucose monitoring and physician notification for a resident with type 2 diabetes mellitus with ketoacidosis without coma and chronic kidney disease. The resident’s March 2026 physician orders directed staff to check blood sugar twice daily and to notify the physician if blood glucose was greater than 250 mg/dl when no sliding scale was ordered, or to follow the hypoglycemia procedure if blood glucose was less than 60 mg/dl. The resident’s 2/25/26 MDS showed the resident was cognitively intact with a BIMS score of 15 out of 15 and was independent in indoor mobility with some help needed for self care. Record review showed the resident’s blood sugar was checked on 2/25/26 at 8:45 p.m. and was 302 mg/dl, but there was no documentation that the physician was notified of the elevated result as ordered. The MARs from 2/18/26 to 3/18/26 also showed missed blood sugar documentation on the afternoon of 2/19/26, 2/20/26, 2/24/26, 2/22/26, and 3/9/26. For 2/19/26, 2/24/26, and 3/9/26, staff documented the resident as unavailable; for 2/20/26, staff documented refusal. There was no further documentation explaining why the resident was unavailable or refused, or what education was provided regarding the refusal, and there was no documentation explaining why no blood sugar was checked on 2/22/26. During interview, RN #2 stated that documenting a resident as unavailable meant the resident was out of the building, at an appointment, at the hospital, or at therapy, but he was not sure what the resident was doing on the dates documented as unavailable. The DON stated that staff should notify the physician immediately if a blood sugar was out of range and said it was not appropriate to chart that a resident was unavailable without explaining why. The DON also stated that if the resident was at an appointment or out of the building, she would still expect the blood sugar to be checked when the resident returned, and she was not sure where the resident was when documented as unavailable on those dates.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent; surveyors determined the rate was 6.5%, with three errors out of 31 opportunities. The facility policy required licensed personnel to compare the prescription label to the order on the eMAR and verify the six medication administration rights before giving medications. During observation, an LPN prepared to administer a lidocaine 4% patch to a resident whose order was for application to the lower back in the morning and removal at bedtime. After the resident stated she had pain in both her lower back and right shoulder, the LPN placed the patch on the upper right shoulder even though there was no active physician’s order for that site, then returned to the cart and obtained a second lidocaine patch for the lower back. In a separate observation, the same LPN administered amlodipine to another resident whose order was for 5 mg orally every day, but she initially gave only one 2.5 mg tablet instead of two tablets to equal the ordered dose. The LPN later stated she had not realized the resident needed 5 mg and acknowledged she should have given another 2.5 mg tablet. The DON stated nurses should have a physician’s order in the EMR before administering a medication and that the LPN should have obtained an order before placing the lidocaine patch on the shoulder.
Missing eMAR Documentation for PRN Hydromorphone
Penalty
Summary
The facility failed to maintain accurately documented medical records for one resident when PRN hydromorphone administrations were not documented in the resident’s eMAR. The resident was admitted with diagnoses including encounter for surgical aftercare following surgery on the digestive system, esophageal obstruction, GERD with esophagitis without bleeding, and dysphagia. The 3/17/26 MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15, independent ambulation with a walker, and need for some help with ADLs; it also indicated the resident complained of difficulty or pain in swallowing. The resident’s pain care plan, revised 3/16/26, addressed acute and/or chronic pain and included interventions such as administering medication per physician’s order and notifying the physician if the regimen was ineffective. A physician’s order dated 3/12/26 directed hydromorphone 4 mg orally every four hours as needed for pain rated 6 to 10. The controlled drug record sheet documented that an LPN administered hydromorphone on 3/12/26 at 10:30 a.m. and 5:30 p.m., and on 3/13/26 at 6:30 a.m., 11:30 a.m., and 5:00 p.m. However, review of the March 2026 eMAR showed no documentation of those hydromorphone administrations. The resident stated she did not receive her PRN pain medication timely after requesting it from the LPN on 3/13/26 and said her pain worsened because the medication was not given quickly enough. The LPN stated she administered the hydromorphone and documented it in the eMAR, but the eMAR contained no such entries. The DON stated nurses should document all narcotic medications after administration in the resident’s eMAR and on the narcotic sheet, and she was unable to locate documentation of the hydromorphone administrations in the eMAR.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakewood Villa | 0.5 mi | ★★★★★ | 0 | 0 |
| Western Hills Health Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Allison Care Center | 1.6 mi | ★★★★★ | 1 | 0 |
| Harmony Pointe Care Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Mountain Vista Health Center | 3.1 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.