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Deficiency Records for Lakewood Rehabilitation and Healthcare Center
A list of the most recent deficiencies for Lakewood Rehabilitation and Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Lakewood Rehabilitation and Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-30 | 2024-10-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-08-30 | 2024-10-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-08-30 | 2024-10-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-30 | 2024-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-30 | 2024-10-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-08-30 | 2024-10-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-30 | 2024-10-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-08-30 | 2024-10-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-30 | 2024-10-01 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2024-08-30 | 2024-10-01 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-08-30 | 2024-10-01 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-08-30 | 2024-10-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-08-30 | 2024-10-01 | N |
| Post nurse staffing information every day. | Health | 2024-08-30 | 2024-10-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-30 | 2024-10-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-30 | 2024-10-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-30 | 2024-10-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-30 | 2024-10-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-08-30 | 2024-10-01 | N |
| Provide or obtain dental services for each resident. | Health | 2024-08-30 | 2024-10-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-08-30 | 2024-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-30 | 2024-10-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-30 | 2024-10-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-08-30 | 2024-10-01 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-08-30 | 2024-10-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-22 | 2024-09-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-22 | 2024-09-11 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-04-23 | 2024-06-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-04-23 | 2024-06-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-21 | 2024-06-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-21 | 2024-06-06 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-03-21 | 2024-06-06 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-21 | 2024-06-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-29 | 2024-06-06 | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2024-03-21 | 2024-04-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-21 | 2024-04-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-21 | 2024-04-23 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-03-21 | 2024-04-23 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-03-21 | 2024-04-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-21 | 2024-04-23 | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2024-02-29 | 2024-04-23 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-02-29 | 2024-04-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-29 | 2024-03-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-29 | 2024-03-21 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-02-29 | 2024-03-21 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-29 | 2024-03-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-05 | 2023-11-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-05 | 2023-11-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-05 | 2023-11-07 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-16 | 2023-11-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-16 | 2023-11-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-16 | 2023-11-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-12 | 2023-08-17 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-12 | 2023-08-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-12 | 2023-08-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-12 | 2023-08-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-25 | 2023-07-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-25 | 2023-07-12 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-25 | 2023-07-12 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-04-06 | 2023-05-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-18 | 2023-01-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-18 | 2023-01-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-18 | 2023-01-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-18 | 2023-01-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-18 | 2023-01-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-11-18 | 2023-01-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-18 | 2023-01-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-18 | 2023-01-04 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2022-11-18 | 2023-01-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-18 | 2023-01-04 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-18 | 2023-01-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-11-08 | 2022-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-08 | 2022-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-08 | 2022-12-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-08 | 2022-12-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-08 | 2022-12-14 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-06-15 | 2022-08-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-15 | 2022-08-02 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-01-26 | 2022-02-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-26 | 2022-02-16 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-21 | Not Fixed | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-21 | Not Fixed | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-21 | Not Fixed | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-07-21 | Not Fixed | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-21 | Not Fixed | Y |
| Provide appropriate foot care. | Health | 2024-07-21 | Not Fixed | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-21 | Not Fixed | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-21 | Not Fixed | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-02-01 | Not Fixed | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-01 | Not Fixed | Y |
| Provide appropriate foot care. | Health | 2024-02-01 | Not Fixed | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-01 | Not Fixed | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-02-01 | Not Fixed | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-01 | Not Fixed | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-25 | Not Fixed | Y |
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