Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 The Oaks At Lakewood during CMS and state inspections, most recent first.
Failure to report injuries of unknown source: Two residents with dementia had injuries that were investigated by the facility, including a humeral fracture and groin abrasions/scratches, but the incidents were not reported to the State Agency Reporting Hotline. Staff later acknowledged the injuries were reportable as injuries of unknown origin.
Inaccurate MDS Assessments: The facility failed to ensure MDS assessments accurately reflected the status of two residents. One resident had a PASSAR level II evaluation and a behavioral health PASSAR notice of determination, but the annual MDS coded the PASSAR item as No. Another resident with stroke, DM, and dementia had conflicting MDS coding for bed mobility and toilet transfers, while staff reported the resident participated in restorative services, could transfer and ambulate in the room, and the MDS was inaccurate.
Incomplete Daily Nursing Staff Posting: The facility failed to ensure the posted nursing staff information accurately reflected actual staffing and hours worked on multiple sampled days. Observation and record review showed the Licensed and Unlicensed Daily Staff posting had scheduled staffing completed, but the actual staff and actual hours sections were left blank, and the DON/Administrator expectation was that the posting be completed thoroughly each day.
The facility failed to implement transmission-based precautions for a Covid-19 positive resident, as multiple staff members entered the room without required PPE. Additionally, two LPNs administered insulin injections to another resident without using gloves, contrary to standard precautions. The DON acknowledged these practices did not meet expectations.
The facility failed to maintain a homelike environment during meal service in the North wing. A resident expressed dissatisfaction with housekeeping cleaning during mealtimes. An observation confirmed that a housekeeping staff member was cleaning a room with disinfectant spray while a resident was eating. The housekeeping manager intervened, instructing the staff to stop cleaning during mealtimes due to the chemicals used.
The facility failed to accurately code MDS assessments for two residents, leading to potential risks for unmet care needs. One resident's dental status was incorrectly recorded, while another's social and dental conditions were inaccurately reflected. These discrepancies were identified through interviews and record reviews.
The facility failed to conduct a timely care conference for a resident with dementia, whose last conference was held in December 2023, despite the requirement for quarterly meetings. Additionally, the care plan for another resident with stroke and dementia was not revised to reflect their preference for baths over showers due to a fear of water over their head, as observed and confirmed by a collateral contact.
A facility failed to provide necessary assistance with ADLs for a resident with heart failure, dementia, and severe malnutrition, risking poor nutrition and diminished quality of life. The resident was observed unable to eat independently, requiring assistance from an LPN. The care plan indicated a need for set-up and moderate assistance, which was not adequately provided.
A facility failed to follow provider's orders for a resident with renal disease by administering blood pressure medication outside prescribed parameters and neglecting bowel medication. Another resident with diabetes received insulin injections without proper skin cleansing or glove use by the LPN, contrary to facility policy.
A resident at high risk for pressure injuries did not receive necessary care to offload their heels as per their care plan. Despite being admitted with chronic pain and diabetes, observations showed the resident's heels were not offloaded on several occasions. Staff interviews confirmed the expectation to follow the care plan, which was not adhered to.
A resident with an above-the-knee amputation and diabetes was at risk for injury due to loose grab bars on sit-to-stand equipment. The maintenance supervisor was aware of the issue but could not fix it without affecting the equipment's functionality. The facility's administrator expected preventative maintenance and external assistance if needed.
A resident with chronic obstructive pulmonary disease and congestive heart failure received oxygen therapy at higher levels than prescribed, contrary to their care plan, which specified 3 liters per minute. Observations showed oxygen settings between 4 and 5 liters per minute. An LPN noted the discrepancy and mentioned the resident's tendency to increase oxygen due to anxiety, which the resident denied. The ADON confirmed that staff should adhere to provider orders and check oxygen settings every shift.
A resident with a femur fracture and dementia did not receive pain medications as ordered, with Roxicodone given for lower pain levels than prescribed. Staff interviews revealed a failure to adhere to pain management protocols, risking incorrect medication administration.
A resident with end-stage renal disease did not receive ordered medications on dialysis days, including an antidepressant, antiarrhythmic, anticoagulant, and pain medication. Facility staff confirmed there was no order to hold medications, and the expectation was to administer them upon the resident's return.
The facility failed to remove expired latanoprost eye drops from a medication cart, as observed during a review. The eye drops, opened on 08/09/2024, were not discarded after six weeks as per the facility's guidelines. The DON confirmed that nurses should date and follow expiration recommendations for eye drops.
A resident with chronic conditions and ill-fitting dentures was not scheduled for a timely dental appointment despite the dentist's visit to the facility. The care plan required coordination for dental care, but the resident was only added to the list for a future appointment after the facility became aware of the request.
A resident with chronic obstructive pulmonary disease and congestive heart failure did not receive a scheduled dental appointment, despite recommendations for new dentures and a hygiene cleaning. The resident expressed a preference for only a bottom denture, but there was no follow-up communication. The Social Services Director was unaware of any discussions with the resident or family, and the Administrator noted the resident was unavailable for a scheduled appointment.
Failure to Report Injuries of Unknown Source
Penalty
Summary
The facility failed to ensure substantial injuries and injuries of unknown source were reported to the State Agency Reporting Hotline for two sampled residents. Resident 7, who had dementia, diabetes, and muscle weakness and was sometimes able to make needs known, had a change of condition on 09/25/2025 for pain and slight swelling in the right upper shoulder. X-ray results showed an acute impacted right humeral neck fracture, and the resident was sent to the ER by ambulance. The facility investigation concluded the fracture was reasonably related to a previous fall and that abuse or neglect was ruled out, but the incident was not reported to the State Agency Reporting Hotline. Resident 9, who had dementia, congestive heart failure, and muscle weakness and was able to make needs known, had a change of condition on 11/05/2025 for a scratch/abrasion in the right inner thigh and another on 11/09/2025 for a scratch/abrasion in the left groin area. The facility investigations concluded the injuries were reasonably related to a fungal infection and were not reportable. Staff later stated Resident 9 had cognitive impairment and could not reliably report how the injuries occurred, and both incidents were identified as injuries of unknown origin that should have been documented on the incident log and reported to the State Agency Reporting Hotline.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure minimum data set (MDS) assessments accurately reflected resident status for 2 of 18 sampled residents. For Resident 11, the electronic health record showed a readmission with diagnoses of depression and schizophrenia, and the resident was able to make needs known. The record also showed a pre-admission screening and resident review (PASSAR) level II evaluation completed on 03/24/2022 and a behavioral health PASSAR notice of determination completed on 10/03/2024. However, the annual MDS coded section A1500 as No for being considered by the State level II PASSAR process to have serious mental illness and/or intellectual disability or a related condition. For Resident 5, the record showed diagnoses including stroke, diabetes, and dementia, and the resident was able to make needs known. Review of the annual and quarterly MDSs showed a decline in bed mobility and toilet transfers, with one MDS assessing the resident as independent and a later MDS assessing the resident as requiring substantial/maximal assistance. Staff interviews stated the resident consistently participated in restorative services at least three times per week and was able to transfer and ambulate in the room without staff assistance, while the care plan included ambulation with a front wheel walker and supervision/touching assist. Staff also stated the resident's MDS was inaccurate and did not meet expectations.
Incomplete Daily Nursing Staff Posting
Penalty
Summary
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, including 01/22/2026 through 01/26/2026. On 01/26/2026 at 9:13 AM, observation showed the posted Licensed and Unlicensed Daily Staff document was dated 01/22/2026, and while the scheduled staff and scheduled staff hours were completed, the actual staff and actual staff hours were blank. During an interview on 01/27/2026 at 8:54 AM, the Staffing Coordinator provided the documents for 01/23/2026, 01/24/2026, and 01/25/2026, and review of those days also showed the actual staff and actual staff hours were blank. Staff D stated the form should have been completed daily to accurately reflect the actual number of staff and hours worked, and the Administrator stated the expectation was that the posting be completed thoroughly each day.
Failure to Implement TBP and Use Gloves During Medication Administration
Penalty
Summary
The facility failed to implement transmission-based precautions (TBP) for a resident who tested positive for Covid-19. Despite the presence of a sign indicating aerosol contact precautions, multiple staff members, including a Certified Nursing Assistant, Maintenance Supervisor, and Assistant Business Office Manager, entered the resident's room without donning the required personal protective equipment (PPE) such as gowns, gloves, N95 masks, and eye protection. The door to the room was also left open, contrary to the guidelines that it should remain closed unless it impacted patient care. Interviews with staff confirmed that the resident still required isolation precautions, and the Infection Preventionist/Staff Development expressed that the expectation was for staff to adhere to these precautions. Additionally, the facility failed to use gloves during the administration of injectable medication to another resident. Two Licensed Practical Nurses administered insulin injections to the resident's abdominal wall without wearing gloves, which is against the standard precautions for medication administration. The Director of Nursing Services acknowledged that not following the posted isolation precautions and standards of medication administration practice did not meet their expectations.
Failure to Maintain Homelike Environment During Mealtimes
Penalty
Summary
The facility failed to provide a homelike environment during meal service in the North wing, which was observed and reported by residents and staff. A resident expressed dissatisfaction with housekeeping activities occurring during mealtimes. An observation confirmed that a housekeeping staff member was cleaning a resident's room with a disinfectant spray while one resident was eating and another resident's meal was still covered. The housekeeping staff member acknowledged using Lysol to disinfect surfaces and admitted that cleaning should not occur during mealtimes unless residents are asked. The housekeeping manager intervened, instructing the staff to stop cleaning during mealtimes due to the presence of chemicals.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of two residents, leading to potential risks for unmet care needs and diminished quality of life. Resident 54, who was admitted with chronic obstructive pulmonary disease and congestive heart failure, had an MDS assessment incorrectly coded in the dental section, indicating no natural teeth or tooth fragments. However, a denture consultation revealed that Resident 54 had decayed, loose teeth, and was missing some upper and all lower teeth, indicating the presence of a partial denture. This discrepancy was acknowledged by the MDS Resource Nurse during an interview. Similarly, Resident 17, diagnosed with Huntington's disease, depression, PTSD, and chronic pain, had an annual MDS assessment that inaccurately reflected their social and dental status. The MDS indicated that Resident 17 usually understood others and had no social isolation or dental issues. However, observations and care plan reviews showed Resident 17 exhibited social isolation and had multiple decayed, broken, and missing teeth, as noted in a dental consult. The MDS Nurse confirmed following the Resident Assessment Instrument manual, yet the coding did not align with the resident's actual condition.
Failure to Conduct Timely Care Conferences and Revise Care Plans
Penalty
Summary
The facility failed to offer a timely care conference for Resident 36, who was admitted with a diagnosis of dementia and was unable to make needs known, having a power of attorney (POA) in place. The last care conference for Resident 36 was held on December 6, 2023, and the POA confirmed not being contacted for a care conference since then. Interviews with the Social Services Director and the Administrator confirmed that care conferences should occur at admission, quarterly, and as needed, and acknowledged that the lack of a care conference for Resident 36 did not meet the facility's expectations. Additionally, the facility failed to revise the care plan for Resident 60, who was admitted with diagnoses including stroke, heart failure, and dementia, and was unable to make needs known. Observations showed Resident 60 displaying discomfort, and a collateral contact revealed that Resident 60 had a fear of water over their head and preferred baths over showers. However, the care plan did not reflect this preference, lacking specific directions for bathing. The Director of Nursing Services stated that the expectation was for residents and their decision-makers to be interviewed about their choices, and the care plan should be updated to reflect the resident's preferences.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a dependent resident, identified as Resident 4, which placed the resident at risk for poor nutrition, weight loss, and a diminished quality of life. Resident 4 was admitted with diagnoses including heart failure, dementia, and severe malnutrition. An assessment tool dated 05/13/2024 indicated that Resident 4 was usually able to understand others. On 10/17/2024, Resident 4 was observed lying in bed, appearing frail and weak. On 10/21/2024, Resident 4 was found in bed with a lunch tray nearby, stating they could not eat or see what was on the plate and could not get themselves up. A Licensed Practical Nurse (LPN) assisted Resident 4 to sit up and eat, but the resident reported the food was cold. The resident's electronic health record showed a focus on ADL self-care performance deficit, with interventions for set-up and moderate assistance, including setting up the tray and encouraging meal intake. During an interview, the Director of Nursing Services (DNS) stated that the expectation was for residents to be set up with their trays and assisted to eat their meals.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to adhere to provider's orders for Resident 125, who was admitted with diagnoses of dependence on renal dialysis and end-stage renal disease. The electronic health record indicated that Resident 125 was prescribed a blood pressure medication that should not be administered if the systolic blood pressure exceeded 130. However, the medication administration record showed that the resident received this medication 15 times, and on five occasions, the systolic blood pressure was greater than 130. Additionally, Resident 125 had orders for bowel medication to be administered after three days without a bowel movement, but the bowel movement tracker revealed that the resident went five days without a bowel movement and was not given the prescribed medication. Interviews with staff confirmed that these actions did not meet the facility's expectations for following provider's orders. For Resident 54, the facility failed to safely administer insulin. The resident, who had diagnoses including heart failure and diabetes, was observed receiving insulin injections without the skin being cleansed with alcohol and without the nurse wearing gloves, contrary to the facility's policy on insulin administration. During an interview, the LPN involved acknowledged that alcohol wipes are usually used prior to administration, indicating a deviation from standard practice. These failures in medication administration practices were observed and documented by the surveyors.
Failure to Offload Heels for High-Risk Resident
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent new pressure ulcers for a resident identified as high risk for pressure injuries. The resident, who was admitted with chronic pain and diabetes, had a care plan intervention to offload heels with pillows due to decreased mobility. However, observations on multiple occasions showed the resident lying in bed without their heels offloaded. Interviews with staff, including the Resident Care Manager and the Director of Nursing Services, confirmed that the expectation was to follow the care plan to offload the resident's heels, which was not done as required.
Loose Grab Bars on Sit-to-Stand Equipment
Penalty
Summary
The facility failed to maintain a safe environment for Resident 14, who was at risk for avoidable injuries due to loose grab bars on the sit-to-stand equipment. Resident 14, who was admitted with an above-the-knee amputation and diabetes, was dependent on staff for transfers and expressed discomfort using the sit-to-stand because of the loose grab bars. Observations confirmed that two Tollos Steady aid Sit to Stand units had grab bars that moved easily and appeared loose. Staff K, the Maintenance Supervisor, acknowledged awareness of the issue since February 2024 but stated that attempts to tighten the bolts resulted in the equipment not functioning properly. The Tollos Steady aid manual specifies that there should be no loose bolts or nuts, and the equipment should not wobble or make unusual noises. The facility's Administrator stated that preventative maintenance was expected, and external assistance should have been sought if concerns arose.
Failure to Follow Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for Resident 54, who was admitted with chronic obstructive pulmonary disease and congestive heart failure. The resident's care plan specified oxygen therapy at 3 liters per minute continuously. However, observations on multiple occasions showed the resident receiving oxygen set between 4 and 5 liters per minute via a nasal cannula connected to an oxygen concentrator. During an interview, a Licensed Practical Nurse (LPN) noted the oxygen was set at 5 liters and mentioned that the resident had previously increased their oxygen due to anxiety, although the resident denied doing so. The Assistant Director of Nursing (ADON) stated that staff were expected to follow the provider's orders and check the oxygen settings every shift.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that pain medications were administered as ordered by the provider for a resident with a fracture of the left femur and dementia. The resident, who required substantial maximum assistance with most activities of daily living, had specific orders for pain management. The orders included Roxicodone 5 mg to be given every four hours as needed for moderate to severe pain levels of seven to ten, and acetaminophen 650 mg for pain levels of one to ten. However, the Medication Administration Record (MAR) showed that Roxicodone was administered for pain levels below the prescribed threshold, specifically for pain levels of three, five, and six on multiple occasions. Interviews with facility staff revealed a lack of adherence to the prescribed pain management protocol. The Resident Care Manager and the Director of Nursing Services (DNS) both acknowledged that the expectation was for pain medications to be given within the specified parameters or for staff to consult the provider to adjust the parameters. The DNS further stated that Tylenol should have been administered before Roxicodone for lower pain levels. This oversight placed the resident at risk of receiving incorrect pain medication, potentially leading to sedation and a diminished quality of life.
Failure to Administer Medications on Dialysis Days
Penalty
Summary
The facility failed to ensure that Resident 125 received medications as ordered when the resident was out of the building for dialysis. Resident 125, who was admitted with diagnoses of dependence on renal dialysis and end-stage renal disease, was unable to make their needs known. The electronic health record indicated that the resident was scheduled to be out of the facility for dialysis on Tuesday, Thursday, and Saturday mornings. However, the medication administration record for August 2024 showed that the resident did not receive any morning medications on these days, including an antidepressant, an antiarrhythmic, an anticoagulant, and a pain medication. Interviews with facility staff revealed a lack of adherence to expected protocols regarding medication administration on dialysis days. Staff M, a Resident Care Manager/LPN, confirmed that there was no provider's order to hold medications on dialysis days and acknowledged that the resident should have received all ordered medications. Similarly, Staff B, the Director of Nursing, stated that residents going to dialysis should have a provider's order to either provide or hold medications on those days and expected staff to administer medications upon the resident's return from dialysis. The failure to administer the ordered medications on dialysis days did not meet the facility's expectations.
Expired Eye Drops Not Removed from Medication Cart
Penalty
Summary
The facility failed to ensure that expired eye drops were removed from use in one of the three medication carts reviewed for medication storage. Specifically, latanoprost eye drops with an open date of 08/09/2024 were found in the Red Wood medication cart during an observation on 10/21/2024. According to the facility's Medication Storage Guidance, latanoprost should be discarded six weeks after opening, which was not adhered to in this case. During an interview, the Director of Nursing Services stated that nurses are expected to date eye drops when opened and follow expiration date recommendations.
Failure to Schedule Timely Dental Care for Resident
Penalty
Summary
The facility failed to schedule a timely dental appointment for Resident 53, who was reviewed for dental services. Resident 53, admitted with chronic kidney disease and chronic obstructive pulmonary disease, was observed to have no upper or lower teeth and reported that their dentures no longer fit due to weight loss. The care plan dated 08/21/2024 indicated a need for coordination of dental care due to oral health problems. Despite the dentist's visit to the facility on 09/16/2024, Resident 53 was not seen, and was only added to the list for a dental appointment on 09/23/2024, with the next available appointment in December. The facility was unaware of Resident 53's request to see the dentist until 10/14/2024, as stated by the Director of Nursing Services.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to schedule a dental appointment for a resident, identified as Resident 54, who was reviewed for dental services. Resident 54 was admitted with diagnoses of chronic obstructive pulmonary disease and congestive heart failure and was capable of communicating their needs. An observation and interview revealed that the resident had missing upper teeth and no bottom teeth, and although they had an upper partial denture, they had not worn it that day. A dental report from January 2024 recommended new dentures and a hygiene cleaning, and a referral in March 2024 was made for updated x-rays and extraction of all upper teeth. However, in July 2024, the resident expressed a desire for only a bottom denture, and there was a lack of follow-up communication regarding this preference. The Social Services Director was unaware of any further discussions with the resident or their family, and the Administrator noted that the resident was scheduled to be seen in September 2024 but was unavailable at that time.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Tacoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tacoma Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 10 | 0 |
| Birch Creek Post Acute & Rehabilitation | 3.7 mi | ★★★★★ | 35 | 0 |
| Alaska Gardens Health And Rehabilitation | 3.7 mi | ★★★★★ | 20 | 1 |
| Agility Health And Rehabilitation | 3.9 mi | ★★★★★ | 24 | 0 |
| Avalon Healthcare - Tacoma | 4.1 mi | ★★★★★ | 1 | 0 |
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