Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Lakewood Health System during CMS and state inspections, most recent first.
A resident with COPD, hemiplegia, and no cognitive impairment was observed with a nebulizer mask on while no staff were present, despite no SAM assessment or order allowing self-administration. The TMA confirmed she set up the treatment and left the room, and the RN and DON verified that a SAM assessment was required but had not been completed.
Failure to provide routine shaving for a resident dependent on staff for personal hygiene. The resident had cognitive impairment, paraplegia, Alzheimer’s disease, and MS, and care planning called for touching assistance with shaving. Staff did not consistently offer or provide shaving, the record lacked refusal documentation, and the resident was observed with visible facial hair on multiple occasions. The resident and family indicated he wanted daily shaving, while an NA said shaving was usually done by bath aides on Mondays and an LPN later shaved him when she noted he needed it.
A resident with cognitive impairment and a history of falls was not adequately supervised, leading to an unwitnessed fall and a fracture. Despite being on a care plan requiring hourly safety checks and toileting every two hours, staff failed to monitor the resident properly. The resident was found in a sleep study room with a fracture, requiring surgical intervention. Staff interviews revealed the care plan was not followed due to workload, and documentation was incomplete.
Nebulizer Treatment Given Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure nebulizer medications were administered safely for one resident who was observed self-administering a nebulizer treatment without having been assessed as safe to self-administer medications. The resident’s quarterly MDS indicated no cognitive impairment and diagnoses including hemiplegia and hypertension, and the care plan identified COPD with interventions for positioning during episodes of difficulty breathing. However, the care plan did not include information about self-administration of medications, and the resident’s EHR did not contain a self-administered medication assessment. The resident’s order review history directed staff to administer ipratropium-albuterol inhalation solution via nebulizer three times daily and as needed for wheezing or shortness of breath, with instructions to rinse the mask and allow it to air dry after each use. The record lacked an order for self-administration, and the EMAR did not include directions for self-administration. During observation, the resident was sitting in a wheelchair with the nebulizer mask on his face and no steam coming from the mask while no staff were present. When staff entered, the resident stated the nebulizer was done and he needed to use the bathroom. The TMA later confirmed she had placed the mask on the resident, turned on the machine, and left the room, and stated she did not sit with the resident during treatments. RN and DON interviews confirmed that a SAM assessment and corresponding order were required for self-administration, and both verified that no SAM assessment had been completed for the resident.
Failure to Provide Routine Shaving for a Dependent Resident
Penalty
Summary
The facility failed to provide routine shaving for a resident who was dependent on staff for assistance with personal hygiene. The resident’s quarterly MDS identified moderate cognitive impairment and diagnoses including paraplegia, Alzheimer’s disease, and multiple sclerosis, and the MDS and CAA both indicated the resident required substantial/maximal assistance with personal hygiene. The comprehensive care plan identified an ADL self-care performance deficit related to impaired balance from multiple sclerosis and included touching assistance from wheelchair level for oral care and shaving. The resident’s medical record lacked documentation of refusal of shaving. During observations, the resident had approximately one quarter inch long white facial hair across the lower face and neck area, and the facial hair remained present during later observations while the resident was in the activity room and then seated with other residents. The resident stated he would like to be shaved daily and later said he needed to be shaved. A family member stated the resident would like to be shaved every day but was unsure whether staff had time to shave him. A nursing assistant stated bath aides usually shaved the resident on Mondays and that she had not offered to shave him that day, while an LPN later confirmed the resident had whiskers and shaved him because he needed to be shaved. The DON stated the expectation was to offer shaving daily unless otherwise care planned, and noted staff were taught to offer shaving daily per resident preference.
Failure to Prevent Resident Wandering and Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent wandering and falls for a resident, resulting in actual harm. The resident, who had a history of cognitive impairment, dementia, and recurrent falls, was at high risk for falls and required substantial assistance with daily activities. Despite being on a care plan that included hourly safety checks and toileting every two hours, the resident was not adequately monitored, leading to an unwitnessed fall that resulted in a fracture of the right leg. On the day of the incident, the resident was last seen in the dining room at 6:15 p.m. and was supposed to be taken to a common area for distraction, but this intervention was not followed. The resident was not located for several hours, and staff failed to document hourly safety checks and toileting as required by the care plan. The resident was eventually found in a sleep study room, having fallen and sustained a fracture, which required surgical intervention. Interviews with staff revealed that the care plan was not followed due to being busy with other tasks, and there was a lack of proper documentation and monitoring. The resident's elopement risk was not adequately assessed, and the care plan was not updated to reflect the need for increased supervision. The failure to adhere to the care plan and provide necessary supervision directly contributed to the resident's fall and injury.
Removal Plan
- The facility implemented corrective action and was determined to be in compliance.
- Both staff involved were immediately removed from the schedule and disciplinary actions were completed for R1's care not followed.
- Audits were put into place for close monitoring of care and care plans.
- R1 would be assessed for a wander guard or memory care placement due to new recent wandering behavior.
- Education was provided to the staff directly involved in incident; NA-A, PCA, and additional education was provided to NA's while audits were completed by the staff nurse every shift.
- Audits continued so that all staff were monitored for frequent checks and residents toileted according to their care plan.
- Expectation for staff would be the care plan followed in its entirety and was made very clear during audits.
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Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Staples
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Oaks Lodge | 15.8 mi | ★★★★★ | 7 | 0 |
| Central Todd County Care Center | 19.8 mi | ★★★★★ | 5 | 0 |
| Cura Of Long Prairie | 27.9 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society - Woodland | 28.1 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society - Bethany | 28.6 mi | ★★★★★ | 4 | 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.