Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Care Center during CMS and state inspections, most recent first.
The facility did not have a certified and credentialed dietary manager overseeing kitchen operations, as the current manager had not completed the required training and was not enrolled in a CDM course. The registered dietician provided only monthly on-site visits and remote support, while the social worker supervised daily duties. This deficiency affected all individuals consuming food from the kitchen due to non-compliance with regulatory standards.
A resident experienced a significant decline in multiple areas, including increased dependence in dressing, bed mobility, transfers, ambulation, and bowel incontinence. Despite these changes, staff did not complete a Significant Change in Status Assessment (SCSA) as required, instead performing only a quarterly MDS. Interviews and observations confirmed the resident's increased care needs and the oversight in assessment.
A discharge MDS assessment for a resident was not completed or transmitted to CMS within the required timeframe. The assessment remained in-progress and unsigned in the electronic medical record, and staff interviews confirmed the omission was not detected until later. The facility's policy did not address procedures for handling discharge MDS assessments.
A resident with severe cognitive impairment experienced significant unplanned weight loss over several weeks, but this was not accurately coded on the MDS by the dietary manager. Despite documentation of weight loss and discussions in high-risk meetings, the MDS was marked as having no or unknown weight loss, contrary to facility policy and CMS guidelines.
A resident with multiple chronic conditions and a recent MRSA diagnosis was placed on transmission-based precautions and prescribed antibiotics. Although staff were instructed to use PPE and later follow modified precautions, the care plan was not updated to include these infection management interventions. Nursing staff confirmed the omission, and the care planning policy was not provided when requested.
A resident with severe dementia and significant weight loss was not comprehensively assessed for nutritional needs, despite ongoing decline and documented eating difficulties. Staff delayed assistance at meals, did not always provide the correct diet texture, and failed to initiate recommended referrals such as a speech evaluation. The facility's required nutritional assessments were not completed, contributing to continued unaddressed weight loss.
A resident with severe cognitive impairment and chewing difficulties was not provided with the ordered mechanical soft, bite-sized diet. Instead, the resident was served foods such as french toast and a fish fillet sandwich on a bun, which did not meet the required texture and size, resulting in difficulty eating. Staff and dietary management confirmed the diet order was not followed, and the issue was attributed to improper meal preparation and lack of daily dietitian oversight.
A resident with respiratory MRSA did not have proper documentation or consistent implementation of transmission-based and enhanced barrier precautions. Staff were unclear about when to use PPE, there was no signage or PPE available outside the room, and the care plan was not updated. The facility's infection control policies were not followed, leading to inconsistent communication and a lack of clear documentation regarding the resident's precaution status.
A resident with a history of traumatic brain injury and stroke was subjected to multiple personal alarms and video cameras that restricted movement without attempts at alternate interventions. The alarms, intended to prevent falls, caused distress and anger in the resident, who was unable to turn them off. Staff used the alarms due to the resident's unsteadiness and inability to provide one-to-one supervision, despite the facility's policy against restraints for convenience.
A resident with severe cognitive impairment and high fall risk fell and fractured her humerus due to the facility's failure to implement care-planned fall interventions. The care plan required a contact guard assist with two staff and a gait belt for transfers, but the resident was left unattended at the bathroom sink, leading to the fall. Staff interviews revealed a lack of adherence to the care plan and failure to ensure necessary equipment was available, contributing to the incident.
The facility failed to ensure that unpasteurized shelled eggs were fully cooked, posing a risk of foodborne illness to residents. Observations revealed that residents were served or attempted to be served over-easy eggs from a batch without verification of pasteurization. Interviews confirmed that the facility had been ordering the same type of eggs for months without checking if they were pasteurized, despite the risk of serious infections. The USDA guidelines were cited, and a policy on food safety was requested but not provided.
A resident, who required assistance and had a history of falls, was observed without an accessible call light while sitting in their room. Despite being cognitively intact and capable of using the call light, it was placed out of reach, contrary to the facility's policy. Staff interviews confirmed the expectation for call lights to be within reach, highlighting a lapse in adherence to care protocols.
A facility failed to maintain confidentiality for 12 residents when a care sheet with personal health data was left unattended in a public area. Staff interviews confirmed that care sheets should be kept private, typically in a pocket, but the sheet was left exposed, compromising resident privacy. A facility policy on privacy was requested but not provided.
A resident with severe cognitive impairment and a history of UTIs was administered antibiotics without proper assessment or adherence to the facility's antibiotic stewardship protocols. Despite a positive urinalysis, the initial antibiotic was ineffective due to resistance, leading to a change in medication. The facility's documentation lacked evidence of symptom assessment before initiating a second course of antibiotics, and there was a delay in receiving culture results, which contributed to inappropriate antibiotic use.
Lack of Qualified Dietary Manager Overseeing Food Services
Penalty
Summary
The facility failed to ensure that a certified and credentialed dietary manager was overseeing and supervising the food preparation and services in the kitchen. The individual acting as the dietary manager had been in the lead/manager position for two years but had not enrolled in the required Certified Dietary Manager (CDM) course, citing the need to cover dietary shifts as the reason for the delay. The facility's registered dietician visited only once per month and provided guidance remotely, while the facility social worker supervised the dietary manager's daily duties. Interviews confirmed that the dietary manager did not possess the necessary qualifications to oversee the kitchen, and the facility was only in the process of looking into appropriate training. Document review showed that the job description for the Food and Nutrition Services Lead did not specify minimum qualifications, and the dietitian services agreement outlined the consultant dietician's role as advisory and supportive, with no daily on-site presence. The lack of a qualified dietary manager had the potential to affect all residents, visitors, and staff who consumed food from the kitchen, as the oversight of food and nutrition services was not in compliance with regulatory requirements.
Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced notable declines in multiple areas of functioning. Review of the Minimum Data Set (MDS) assessments showed that the resident went from requiring maximum assistance with dressing, being independent with bed mobility, and needing maximum assistance with transfers and ambulation, to being dependent in dressing, bed mobility, and transfers, and unable to ambulate. The resident also became always incontinent of bowel, indicating a significant change in status across several domains. Despite these changes, only a quarterly MDS was completed instead of a significant change MDS as required. Interviews and observations confirmed the resident's increased dependence, with nursing assistants needing to provide two-person assistance for transfers and full assistance for bed mobility and toileting. The registered nurse responsible for MDS completion acknowledged that the resident's decline should have triggered a significant change assessment, as the changes were not expected to resolve within two weeks and affected multiple areas of health status. Facility policy and CMS guidelines both require a comprehensive assessment in such cases, but this was not done, resulting in the deficiency.
Failure to Complete and Transmit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) database within the required timeframe for one resident. According to the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a discharge assessment must be transmitted within 14 calendar days of completion. In this case, the resident was admitted and later discharged home with his son, but the discharge MDS remained in-progress and unsigned in the electronic medical record. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the discharge MDS was neither completed nor submitted as required, and the omission was not identified until after the fact. The facility's Resident Assessment Instrument policy did not specify procedures for handling discharge MDS assessments.
Failure to Accurately Code Significant Weight Loss on MDS
Penalty
Summary
The facility failed to ensure accurate coding of weight loss on the Minimum Data Set (MDS) for a resident with severe cognitive impairment. The resident experienced significant weight fluctuations over a three-month period, including a weight loss of over 14% in nine weeks and over 16% in twelve weeks, as documented in the Weights and Vitals Summary. Despite these documented losses, Section K: Swallowing/Nutritional Status of the resident's significant change MDS was incorrectly coded as having no or unknown weight loss or gain since the last assessment period. Interviews with facility staff revealed that the dietary manager, who was responsible for completing Section K of the MDS, did not realize the error and acknowledged that the resident had experienced weight loss, which had been discussed in high-risk team meetings. The registered dietician noted inconsistencies in the recorded weights and stated that the resident's intake was poor, further supporting the presence of significant weight loss. The director of nursing confirmed that the resident was being monitored for weight loss and should have been coded accordingly on the MDS. The facility's policy and the CMS RAI User's Manual require accurate and comprehensive assessment and coding of resident weight changes, which was not followed in this instance.
Failure to Update Care Plan for Infection Management and Precautions
Penalty
Summary
The facility failed to revise a resident's care plan to include interventions for infection management after the resident tested positive for MRSA and was placed on transmission-based precautions. The resident, who was cognitively intact but dependent on staff for activities of daily living, had diagnoses including diabetes, renal insufficiency, and COPD. Following a positive sputum culture for MRSA and a diagnosis of pneumonia, the resident was prescribed multiple antibiotics and placed on precautions upon return from the hospital. Staff were instructed to wear full PPE when caring for the resident, and later, modified precautions were implemented based on a physician's order due to the resident's mental health needs. Despite these changes in the resident's condition and care requirements, the care plan was not updated to reflect the necessary infection control interventions or the modified precautions. Interviews with nursing staff confirmed that the care plan should have included these interventions, as staff rely on the care plan to guide resident care. The director of nursing also stated that care plans are updated by nurses and reviewed by staff for changes. However, the care plan for this resident did not include the required transmission-based precautions or infection management interventions, and a care planning policy was requested but not provided.
Failure to Comprehensively Assess and Address Resident Weight Loss
Penalty
Summary
The facility failed to comprehensively assess and develop interventions to prevent or reduce continued weight loss for a resident with severe cognitive impairment and dementia. The resident experienced significant unplanned weight loss over a three-month period, with documented weights showing a decline from 104.8 lbs. to 87.6 lbs., representing a 16.41% loss. Despite a care plan identifying unplanned weight loss and interventions such as referral to a dietician, meal assistance, and monitoring of food intake, the resident's medical record lacked evidence of a comprehensive assessment addressing the ongoing weight loss. Observations revealed that the resident had difficulty eating independently, particularly with certain food textures, and required significant prompting and assistance from staff. Staff interviews confirmed that the resident struggled with chewing and needed frequent reminders and coaching to eat. The resident was served food that did not always match the ordered diet texture, and staff sometimes delayed assistance at meals. The dietary manager and consultant dietician communicated about the resident's weight loss, but a comprehensive nutritional assessment was not completed, and recommended referrals, such as for a speech evaluation, were not initiated. The facility's policy required a thorough nutritional assessment, including review of diet, oral status, lab values, medications, and other relevant factors, but this was not completed for the resident. The consultant dietician acknowledged that comprehensive assessments had not been kept up to date, and the dietary manager had not implemented a more detailed assessment form provided by the dietician. The lack of a comprehensive assessment and timely interventions contributed to the resident's continued weight loss and inadequate management of her nutritional needs.
Failure to Provide Ordered Diet Texture to Resident with Chewing Difficulties
Penalty
Summary
The facility failed to provide the prescribed diet texture to a resident with severe cognitive impairment who required supervision and setup assistance for eating. The resident had an order for a mechanical soft, bite-sized diet (IDDSI #6), but was observed being served foods such as french toast cut into large triangles and a fish fillet sandwich on a bun, both of which did not meet the required soft and bite-sized criteria. The resident struggled to eat the french toast, was unable to break off bites, and had difficulty manipulating the food, ultimately only eating bite-sized watermelon when it was provided. Staff interviews confirmed that the resident had trouble chewing and would only take very small bites, and that bread and toast were not appropriate for the ordered diet texture. The dietary manager acknowledged that the resident should not have been served foods like french toast or hamburger buns, and that all dietary staff had been trained on diet orders and could reference posted diet information in the kitchen. The registered dietitian confirmed that the IDDSI #6 diet required soft, easily mushed, bite-sized foods and that bread products were not suitable without a specific consult. The director of nursing was aware of the issue and noted the absence of a qualified dietitian on site every day. Facility policy required assessment of nutritional needs by a registered dietitian or designated personnel, including review of diet orders and the need for assistance.
Failure to Document and Implement Precautions for Resident with Respiratory MRSA
Penalty
Summary
The facility failed to ensure proper documentation and implementation of transmission-based precautions (TBP) and enhanced barrier precautions (EBP) for a resident diagnosed with respiratory MRSA. The resident, who was cognitively intact but dependent on staff for activities of daily living, had a history of diabetes, renal insufficiency, and COPD. After a positive sputum culture for MRSA and a course of antibiotics, there was no clear documentation in the medical record regarding when TBP were initiated or discontinued, nor the rationale for these decisions. Additionally, interventions and the use of PPE were not consistently documented or communicated to staff. Observations revealed that there was no signage for EBP or PPE available outside the resident's room, and the resident was seen coughing and spitting phlegm in a public area without covering his mouth. Interviews with staff indicated inconsistent use of PPE and confusion about the resident's precaution status. Some staff reported not wearing PPE in the week prior, and there was a lack of clarity on when precautions were to be started or stopped. The care plan was not updated to reflect TBP, and staff relied on informal communication methods rather than documented protocols. The facility's policies required contact precautions for MDROs like MRSA, with clear signage and documentation when precautions were implemented or discontinued. However, the infection control nurse and DON were unable to provide evidence of proper documentation or a clear process for discontinuing precautions. The medical director stated that precautions should remain until the infection was resolved, but was not involved in the decision to discontinue them. The lack of documentation, inconsistent communication, and failure to update the care plan contributed to the deficiency in infection prevention and control for the resident with respiratory MRSA.
Failure to Identify and Address Use of Restraints
Penalty
Summary
The facility failed to identify the use of restraints for a resident, referred to as R3, by employing multiple personal alarms and video cameras that restricted R3's movement without attempting alternate interventions to prevent falls. R3 was readmitted to the facility with a history of traumatic brain injury, cerebrovascular disease, depression, and insomnia, and was identified as having moderately impaired cognition. The care plan for R3 indicated a high risk for falls and required alarms in bed, recliner chair, and dining room chair due to an inability to comprehend safe choices and ask for assistance. Observations and interviews revealed that R3 reacted negatively to the alarms, which were loud and caused distress. R3 expressed frustration and anger towards the alarms, stating they were annoying and he was unable to turn them off. Staff interviews indicated that the alarms were used because R3 was unsteady and needed supervision, but they were unable to provide one-to-one supervision. The use of a camera to monitor R3 was also noted, with staff acknowledging that R3 was aware of the camera and was always watching it. The facility's policy on restraints indicated that residents have the right to be free from any physical or mechanical restraint imposed for discipline or convenience. However, the facility did not attempt other interventions prior to using alarms, and the family member of R3 stated they had not requested the alarms. The facility's approach was based on therapy recommendations and the belief that alarms were the only way to ensure staff knew if R3 got up, despite R3's adverse reactions to the alarms.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to implement fall interventions as care planned for a resident identified as a high fall risk, resulting in actual harm. The resident, who had severe cognitive impairment and required substantial assistance for activities of daily living, fell and sustained a fracture of the right humerus. The care plan specified that the resident required a contact guard assist with two staff and a gait belt for transfers, and was unsafe to walk, necessitating stand-pivot transfers only with two-person assistance. However, the care plan did not specify whether the resident could be left unattended at the bedside. On the morning of the incident, a nursing assistant left the resident unattended at the bathroom sink to retrieve a wheelchair, during which time the resident fell. The nursing assistant did not have the necessary equipment, such as a gait belt and walker, readily available, and did not request assistance. Interviews with staff revealed that the resident was known to be impulsive and unsteady, requiring constant supervision and contact guard assist. Despite this, the nursing assistant turned her back on the resident multiple times during care, leaving the resident unsupported and at risk of falling. The facility's policy on falls prevention emphasized the need for appropriate supervision and assistive devices to prevent avoidable accidents. However, the staff did not adhere to the care plan, which required a contact guard assist and the use of a gait belt. The lack of adherence to the care plan and failure to ensure the availability of necessary equipment contributed to the resident's fall and subsequent injury.
Removal Plan
- Evaluation by physician, PT/OT, Orthopedics
- Immobilize right arm with sling
- Change dressing routinely
- Education to all staff regarding assistive devices, the need for all equipment to be available to the resident when needed
- Care plan was updated for dressing and transferring needs
- Audit of all resident walkers to ensure that they were available and had their name on it
- Interviewed cognitively intact residents that use gait belt for audit of gait belt use by staff
- Creating a walk to dine policy
- Weight will be monitored and intakes to ensure continued eating and maintaining weight
Failure to Ensure Safe Preparation of Eggs
Penalty
Summary
The facility failed to ensure that unpasteurized shelled eggs were fully cooked and prepared in a manner to prevent foodborne illness. This deficiency was identified during an observation, interview, and document review process. The issue had the potential to affect all 24 residents, with specific mention of five residents who regularly ordered undercooked eggs for breakfast. During a kitchen tour, it was observed that the cook's refrigerator contained seven flats of eggs without any indication that they were pasteurized. The cook assumed the eggs were pasteurized, as residents ordered eggs over-easy, which should be pasteurized if served undercooked. Further observations revealed that residents were served or attempted to be served over-easy eggs from the unverified batch. Interviews with the social worker and dietician confirmed that the facility had been ordering the same type of eggs for six months without verifying if they were pasteurized. The dietician emphasized the risk of using unpasteurized eggs for undercooked dishes, which could lead to serious infections. The administrator also stated the expectation for food to be prepared safely, using pasteurized eggs. The USDA guidelines were cited, highlighting the risk of salmonella from improperly cooked eggs. A policy regarding food safety was requested but not provided.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a call light or device to alert staff was accessible for a resident, identified as R21, who was observed without a way to call for assistance while sitting in their room. R21 was cognitively intact and required moderate to maximum assistance for transfers, having sustained a fall since admission. The care plan for R21, dated 8/13/24, indicated a dependency on staff for various needs and highlighted a risk for falls, with interventions including the provision of adaptive equipment. However, during observations on 9/9/24 and 9/10/24, R21 was seen sitting in a recliner without a call light within reach, as it was placed on a table three to four feet away, making it inaccessible. Interviews with staff revealed that R21 was capable of using the call light and should have had it within reach at all times. Nursing assistant NA-D was observed transferring R21 to the recliner and leaving the room without providing the call light or reacher device. Both NA-A and RN-B acknowledged the expectation for residents to have call lights accessible, with RN-B suggesting a splitter for the call light cords to ensure accessibility. The director of nursing confirmed the facility's policy that all residents should have call lights within reach, and staff were trained to check on residents' needs during deliberate rounding. The facility's policy, dated 4/1/14, emphasized prompt responses to residents' needs and the importance of positioning call lights conveniently for use.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of personal and medical records for 12 residents. During an observation, a care sheet containing sensitive information such as urinary intake/output, fasting blood sugars, and other personal care needs was found unattended on a tabletop in a public hallway. This area was accessible to staff, visitors, and residents, allowing them to view the information without obstruction. Nursing assistant (NA)-B admitted to leaving the care sheet on the table as part of her routine, acknowledging that others could view the information without her knowledge. Interviews with various staff members, including nursing assistants, trained medication aides, a registered nurse, and the director of nursing, confirmed that the care sheets should be kept private, typically folded and in a pocket. Despite this expectation, the care sheet was left exposed, compromising resident privacy. The facility's policy on privacy was requested but not provided, indicating a potential gap in policy enforcement or availability.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement antibiotic stewardship protocols for a resident identified as having been taking an antibiotic. The resident, who had severe cognitive impairment and diagnoses including dementia and urinary tract infections, was found to have a positive urinalysis on a specific date. Despite the facility's policy to use a UTI tracking form and monitor symptoms before initiating antibiotics, the resident was started on ciprofloxacin before culture results were received, which later showed resistance to the antibiotic. This led to a change in medication to Rocephin. The facility's documentation lacked evidence of any assessment of signs and symptoms of infection before initiating the second course of antibiotic treatment. Interviews with nursing staff revealed that the family had requested further intervention due to the resident's decreased appetite, which they believed was a symptom of a UTI. However, there was no evidence of a patient assessment or non-pharmacological interventions, such as increased fluid intake, being implemented before contacting the physician for additional antibiotics. The director of nursing acknowledged that there was a lag in receiving culture results, which hindered timely decision-making. The facility's infection control policy aimed to optimize antibiotic use, but the lack of timely culture results and proper documentation of symptoms led to inappropriate antibiotic administration. The facility was working on improving their documentation and protocols to ensure appropriate use of antibiotics.
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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 Baudette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warroad Care Center | 36.6 mi | ★★★★★ | 13 | 0 |
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