Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lakewood Post Acute And Rehabilitation during CMS and state inspections, most recent first.
The facility did not conduct annual performance reviews for five CNAs, as required by their policy, leading to a lack of in-service education based on these reviews. The DON, new to the position, confirmed the absence of evaluations, which also affected staff training in abuse and dementia.
The facility failed to maintain an effective infection control program, with staff not adhering to PPE protocols and inadequate cleaning practices. Observations included improper PPE use by various staff members and unhygienic cleaning methods by housekeeping, such as not allowing disinfectant dwell time and using contaminated rags. Interviews revealed a lack of understanding of infection control protocols, contributing to an unsafe environment for residents.
The facility did not ensure all staff completed mandatory annual training on abuse prevention and dementia management, with 17 staff missing abuse training and 15 missing dementia training. The DON, new to her role, was unaware of why the training was incomplete, highlighting a lapse in training program management.
A facility failed to obtain informed consent for a psychotropic medication before its administration to a resident with major depressive disorder. Despite being cognitively intact, the resident did not have documented informed consent for Bupropion, which was administered for depression. Staff interviews revealed that obtaining consent was the responsibility of the admitting nurse, but the oversight was not identified during chart audits by the DON or ADON.
Two residents in the facility lacked comprehensive care plans addressing their specific medical needs. One resident, dependent on oxygen, did not have a care plan or physician's order for oxygen therapy, while another resident with contractures did not have her use of splints documented in her care plan. Staff interviews confirmed the absence of these critical care components, despite facility policy requiring comprehensive care plans within seven days of assessment.
A resident with rheumatoid arthritis and osteoporosis used knee splints for contracture management without a physician's order for nearly a year. The facility failed to ensure a physician's order was obtained for the use of these specialized medical devices, as required for proper care coordination. Staff interviews revealed a lack of awareness and communication regarding the necessity of such orders.
A resident requiring oxygen therapy did not have a physician's order or care plan documented, and their portable oxygen tank was not turned on during use. Staff interviews confirmed the absence of necessary documentation and highlighted the importance of having a physician's order and care plan for administering oxygen therapy.
A resident requiring dialysis services did not receive care consistent with professional standards due to incomplete documentation on dialysis communication forms. The facility failed to complete the post-dialysis sections for four sessions, despite physician orders requiring this documentation. Interviews with staff confirmed the oversight, with suggestions that agency staff might have contributed to the issue.
A facility failed to provide appropriate mental health services to a resident with a history of trauma and suicide attempts. Despite the resident's request to see a therapist and signs of depression, there was no referral to a psychologist, and staff were unaware of the resident's significant traumatic events. The social services director did not initiate behavior monitoring for suicidal ideations, contributing to the deficiency.
A facility failed to consistently follow a physician's order for a renal diet for a resident with acute kidney failure. The resident, who was cognitively intact, reported receiving high potassium foods like potatoes and tomatoes, which were not consistent with her prescribed diet. The issue was linked to errors in the facility's electronic ticket system used for meal orders, which occasionally produced inaccuracies. The registered dietitian and nutrition service manager acknowledged the problem, with the dietitian only checking meal tickets when present.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for five certified nurse aides (CNAs), which is a requirement according to their policy and procedure. The policy, revised in September 2024, mandates that each employee's job performance be reviewed at least annually, with evaluations used to determine training needs and other employment decisions. However, the facility was unable to provide documentation of annual performance evaluations for CNAs hired between July 2023 and March 2024. This lack of evaluations also meant that the CNAs did not receive regular in-service education based on the outcomes of these reviews. During interviews, the Director of Nursing (DON), who had been in the position for six weeks at the time of the survey, acknowledged that the annual performance reviews had not been completed. The absence of these evaluations and subsequent training represents a failure to adhere to the facility's own policies, potentially impacting the quality of care provided by the CNAs. The report also cross-references a failure to ensure all staff had abuse and dementia training, indicating broader issues with staff training and evaluation processes.
Infection Control Deficiencies in PPE Use and Housekeeping Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper use of personal protective equipment (PPE) and inadequate cleaning practices. Staff members, including the assistant director of nursing (ADON), a housekeeper, the nutrition service manager (NSM), and an oxygen supplier, were observed not adhering to proper PPE protocols. The ADON did not disinfect or dispose of a face shield after exiting a droplet precaution room. The housekeeper wore the same surgical mask across multiple rooms, including those under droplet precautions, and did not apply the correct PPE. The NSM improperly donned PPE after entering a resident's room to retrieve it, and the oxygen supplier entered a droplet precaution room without PPE and failed to perform hand hygiene upon exit. Housekeeping practices were also found to be deficient. A housekeeper was observed cleaning resident rooms without allowing the required dwell time for disinfectants to be effective. The housekeeper used the same rag for different surfaces without proper disinfection, failed to clean from cleanest to dirtiest areas, and did not clean high-touch areas such as call lights, bed controls, and door handles. The housekeeper also used unhygienic methods, such as using a rag dipped in toilet water to clean the toilet and surrounding areas. Interviews with staff revealed a lack of understanding and adherence to infection control protocols. The infection preventionist (IP) and housekeeping and laundry manager (HLM) provided conflicting information about PPE storage and cleaning procedures. The IP was unaware of the specific disinfectant used by housekeeping, and the HLM incorrectly stated the dwell time for the disinfectant. These deficiencies indicate a systemic failure in the facility's infection control practices, contributing to an unsafe environment for residents.
Failure to Complete Mandatory Staff Training on Abuse and Dementia
Penalty
Summary
The facility failed to provide mandatory annual training on abuse prevention and dementia management to all staff members. Specifically, 17 out of 74 staff members did not complete the required annual abuse prevention training, and 15 out of 74 staff members did not complete the annual dementia management training. This deficiency was identified through a review of the facility's training records and confirmed by the regional director of clinical services, who acknowledged that not all staff had completed the necessary training. Interviews with the director of nursing (DON) revealed that she had assumed her role six weeks prior to the survey and was responsible for tracking staff training. The DON stated that training on abuse and dementia was supposed to be completed upon hire and annually, managed by human resources. However, she was unaware of the reasons why the training had not been completed for all staff members, indicating a lapse in the facility's training program management.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medication to a resident prior to its first administration. The resident, who was under 65 years old and diagnosed with type two diabetes mellitus, major depressive disorder, and heart failure, was cognitively intact with a BIMS score of 15 out of 15. The resident's medical records indicated the use of Bupropion for depression, with orders for 150 mg and 300 mg doses. However, the facility did not secure informed consent, which should have included a discussion of the risks associated with the medication, before administering the first dose on February 16, 2025. Interviews with facility staff, including an LPN, the social service director, and the DON, revealed that it was the responsibility of the admitting nurse to obtain informed consent for psychotropic medications. The DON stated that consent forms were part of the admission packet and that new admission charts were audited by herself or the ADON. Despite these procedures, the informed consent for the resident's medication was not obtained, and the DON was unable to determine how this oversight occurred.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident #18, who was oxygen-dependent, did not have a care plan addressing his use of oxygen, nor was there a physician's order for the oxygen therapy. Observations confirmed the resident was using oxygen, but the necessary documentation was missing. Interviews with staff, including a registered nurse, the assistant director of nursing, and the director of nursing, revealed that they were aware of the requirement for a care plan and physician's order for oxygen therapy, but these were not in place for Resident #18. Resident #15, who had multiple diagnoses including rheumatoid arthritis and osteoporosis, also lacked a comprehensive care plan addressing her use of splints for contracture management. Despite having contractures and using knee splints as part of her therapy, the care plan did not reflect these interventions. Interviews with staff, including an LPN and the director of rehabilitation, indicated that the nursing department was responsible for updating care plans with therapy interventions, but this was not done for Resident #15. The facility's policy required comprehensive care plans to be developed within seven days of the MDS assessment, including all triggered Care Assessment Areas. However, the care plans for both residents were incomplete, lacking critical information about their medical devices and therapies. This oversight in care planning was identified through record reviews, observations, and staff interviews, highlighting a failure to adhere to the facility's policy and ensure resident needs were fully addressed.
Lack of Physician Order for Splint Use in Resident Care
Penalty
Summary
The facility failed to ensure that a resident received care and services according to acceptable standards of clinical practice. Specifically, the facility did not have a physician's order for the use of specialized medical devices, such as splints, for a resident with contractures. The resident, who had multiple diagnoses including rheumatoid arthritis and osteoporosis, had been using knee splints since May 2024 as part of her physical therapy regimen. However, there was no physician's order for the splints until March 2025, during the survey, despite documentation indicating their use for nearly a year. Interviews with staff revealed a lack of awareness and communication regarding the necessity of a physician's order for the use of splints. An LPN and the Director of Rehabilitation were unaware of the requirement for a physician's order, and the Director of Nursing acknowledged the importance of having such an order for collaboration of care. The therapy department was responsible for assessing and identifying necessary devices, but the process for obtaining physician orders was not followed, leading to the deficiency identified during the survey.
Failure to Ensure Proper Oxygen Therapy for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy. The resident, who was over 65 years old and had diagnoses including oxygen dependency and shortness of breath, did not have a physician's order for oxygen therapy documented in their medical record. Observations revealed that the resident was using a nasal cannula connected to a portable oxygen tank that was not turned on, and there was uncertainty about the correct oxygen concentration setting. Additionally, the resident's care plan did not include interventions for oxygen therapy, and there was no documentation of a physician's order for the therapy. Interviews with facility staff, including a CNA, RN, ADON, and DON, confirmed the absence of a physician's order and care plan for the resident's oxygen therapy. The staff acknowledged that a physician's order and care plan are necessary for administering oxygen therapy and that the portable oxygen tank should be operational when in use. The ADON and DON both emphasized the importance of having these documents to guide the resident's care, but they were unable to locate them in the resident's medical record.
Incomplete Dialysis Communication Forms for a Resident
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for Resident #75, who required such services. The deficiency was identified through observations, record reviews, and interviews, revealing that the facility did not consistently complete the pre-dialysis facility assessment section on the dialysis communication form for the resident. The facility's policy required communication of various medical details between the nursing home and the dialysis center, including medication administration, treatment orders, and resident responses to dialysis, but these were not adequately documented. Resident #75, over the age of 65, was admitted with diagnoses including metabolic encephalopathy, congestive heart failure, end-stage renal disease, and type 2 diabetes mellitus. The resident had moderate cognitive impairments and required dialysis services. A review of the dialysis communication book and binders revealed that the post-dialysis sections of the communication forms were not completed for four dialysis sessions since the resident's admission. This lack of documentation was contrary to the physician's orders, which required vital signs and dialysis forms to be completed pre and post-dialysis. Interviews with facility staff, including RN #1, the ADON, and the DON, confirmed the incomplete documentation. RN #1 acknowledged the nurses' responsibility to complete the forms, while the ADON suggested that agency staff might have contributed to the oversight. The DON emphasized the importance of the communication forms for ensuring awareness of the resident's medical needs and stated that it was the floor nurse's responsibility to complete the forms. Despite the facility's policy requiring agency staff to review a binder of policies, the forms remained incomplete, indicating a lapse in adherence to the facility's procedures.
Failure to Provide Mental Health Services to Resident with Trauma History
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with mental disorder and psychosocial adjustment difficulty. The resident, aged 66, was admitted following a car accident and had a history of suicide attempts and trauma, including the recent loss of her mother and the anniversary of her nephew's murder. Despite expressing feelings of depression and requesting to see a therapist, the resident did not receive the necessary mental health services, and there was no documentation of a referral to a psychologist for evaluation and treatment. The resident's care plan included interventions such as encouraging verbalization of feelings and monitoring for signs of decreased psychosocial well-being. However, the facility did not have a physician's order to monitor for potential signs and symptoms of suicidal ideation. Interviews with staff revealed a lack of awareness of the resident's significant traumatic events and history of suicide attempts. The social services director acknowledged the resident's risk for psychosocial distress but did not initiate behavior monitoring for suicidal ideations or inform the staff of the resident's history. The social services director stated that the facility did not have mental health providers and only arranged mental health services for residents after discharge. The director also mentioned that a resident with a history of suicidal ideations or attempts would warrant behavior monitoring, but this was not implemented for the resident. The lack of communication and appropriate monitoring contributed to the deficiency in providing necessary mental health services to the resident.
Failure to Follow Prescribed Renal Diet for Resident
Penalty
Summary
The facility failed to consistently follow the physician's order for a renal diet for Resident #5, who was diagnosed with acute kidney failure, diabetes, and protein calorie malnutrition. The resident, who was cognitively intact, reported receiving foods that were not consistent with her prescribed renal diet, such as potatoes, tomatoes, and bananas, which are high in potassium. This inconsistency was observed during a lunch service when the resident received tomatoes on her tray, which she left uneaten. The resident had been educated on her diet and was aware of the need to avoid high potassium foods due to her kidney condition. The deficiency was linked to the facility's electronic ticket system, which was used to print meal tickets with residents' diet orders. The registered dietitian (RD) and nutrition service manager (NSM) acknowledged that the system occasionally produced errors, especially when too many specifics were entered into a resident's diet order. The NSM was aware of the error with the tomatoes but not of other instances where high potassium foods were provided. The RD worked part-time and checked meal tickets for accuracy only when present, indicating a lack of consistent oversight in ensuring diet orders were followed correctly.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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) |
|---|---|---|---|---|
| Hallmark Nursing Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Heights Care & Rehabilitation Llc | 2.7 mi | ★★★★★ | 9 | 0 |
| Villa Manor Care Center | 2.7 mi | ★★★★★ | 11 | 0 |
| Westwood Post Acute | 3.5 mi | ★★★★★ | 0 | 0 |
| Parkview Care Center | 3.5 mi | ★★★★★ | 1 | 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.