Lakewood Health System

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

50.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.16 therapist hours per resident per day in 2026Q1 — more than 14% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 87 beds and averages 82.0 residents a day — about 94% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.41 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.06 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.88 hrs/resident/day on weekends vs 4.62 on weekdays — 16% thinner on weekends. RN hours go from 0.98 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 34% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

• Actual harm · G2024-07-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure adequate supervision to prevent wandering to unsafe places and falls for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm to R1 when she fell and sustained a fracture to the right leg. The facility implemented corrective action so the deficient practice was issued at past non-compliance. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], identified R1 required supervision with eating, oral hygiene, toileting, and shower/bathing, partial to moderate assistance personal hygiene, roll left to right, sit to lying, lying to sitting, and toilet transfers. Substantial to maximum assistance to transfer from chair to bed and sit to stand machine. R1 was frequently incontinent of bladder and always continent of bowel. R1's diagnoses included non-traumatic brain dysfunction, arthritis, osteoporosis, Alzheimer's, and dementia. R1's medications include diuretics (increased urine output). R1's Fall risk assessment…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · D2026-02-19 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 resident (R44) who were observed to self-administer a nebulizer and had not been assessed as safe to self-administer medications. R44's quarterly Minimum Data Set (MDS) dated [DATE], indicated R44 had no cognitive impairment and had a diagnosis which included hemiplegia (one-sided weakness), and hypertension (high blood pressure). Furthermore, R5 required maximum assistance with bed mobility, transfers, toileting, and personal hygiene.R44's care plan revised 5/29/25, identified R44 had chronic obstructive pulmonary disease (COPD). Care plan interventions were to elevate head of bed to 30 degrees or propped on pillows or out of bed upright in a chair during episodes of difficulty breathing. Care plan lacked information regarding self-administration of medications.Review of R44's electronic health record (EHR) lacked a self-administered medication (SAM) assessment.R44's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to provide routine shaving for 1 of 1 residents (R39) who was dependent on staff for assistance with personal hygiene.Findings Include: R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 had moderate cognitive impairment and diagnoses which included; paraplegia (paralysis of lower body), Alzheimer's disease and multiple sclerosis (chronic neurological disorder that affects the nerve cell coverings and may cause numbness, weakness, vision changes and fatigue). R39's MDS identified R39 required substantial/maximal assistance with personal hygiene. R39's Functional Abilities Care Area Assessment (CAA) dated 6/27/25, identified R39 required substantial/maximal assistance with personal hygiene. R39's CAA identified R39 was able to verbalize, but staff also had to anticipate his needs. R39 needed and received staff assistance with all activities of daily living (ADL) tasks. R39's comprehensive care plan revised 12/10/25,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-11-08 · tag F0576 — pattern
  Ensure residents have reasonable access to and privacy in their use of communication methods.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 5 of 5 residents (R2, R40, R46,R49, R27) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 74 residents residing in the facility. Findings include: During a resident council meeting on 11/7/23 at 2:02 p.m., five residents attended. All five residents, R2, R40, R46, R49, R27, confirmed mail was not delivered on Saturdays at the facility, and they had to wait until Monday to receive their mail. During an interview on 11/7/23 at 3:09 p.m., activity assistant (AA)-A indicated activity staff delivered mail to residents. AA-A stated they did not deliver mail to residents on Saturday and indicated mail had not been delivered to the facility on Saturdays. During an interview on 11/7/23 at 3:15 p.m., business office assistant (BOA)-A indicated she sorted the mail the residents received on Monday through Fridays and placed the mail activity mail box for resident delivery. BOA-A indicated she was unsure if mail was delivered on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-11-08 · tag F0585 — failed to handle grievances — pattern
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and document review, the facility failed to ensure grievance procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired, for 5 of 5 residents (R2, R40, R46, R49, R27) reviewed for grievances. This deficient practice had the potential to affect all 74 residents residing in the facility. Findings include: During a resident council meeting on 11/7/23 at 2:02 p.m., five residents attended. All five residents, R2, R40, R46, R49, R27, confirmed they were not aware of how to file a grievance at the facility. During an interview on 11/7/23 at 4:00 p.m., social service assistant (SSA)-A indicated the grievance procedure was reviewed upon admission with the residents and a copy of the procedure was included in the admission packet. SSA-A stated three facility staff members were listed on the grievance procedure form for residents or representatives to contact if they had a concern, or they could contact the ombudsman. SSA-A indicated if residents wished to file…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-11-08 · tag F0623 — isolated
  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to notify the ombudsman of a facility initiated transfer for 1 of 1 residents (R9) reviewed for hospitalization. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 was cognitively intact, and had diagnoses which included: stroke, hemiplegia (one sided paralysis or weakness) and peripheral vascular disease (blood circulation disorder). Indicated R9 required assistance with self care and mobility. Review of R9's progress notes from 8/28/23 to 8/30/23, identified the following: - on 8/28/23 at 1:17 p.m., nurse was notified from nurse at vascular appointment, that the procedure went well, but R9's blood pressure dropped significantly. R9 was being admitted for observation, with plan to return to facility the next day. Family notified and verbal bed hold completed. - on 8/30/23 at 12:20 p.m., R9 returned to the facility. During an interview on 11/7/23 at 10:49 a.m., social service designee (SSD)-A indicated her usual process…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-08-11 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and document review, the facility failed to implement assessed intervention to prevent reoccurrence following a respiratory care incident and facility failed to develop a respiratory care plan for 1 of 4 residents (R2) reviewed for respiratory care. Findings include: R2's admission Minimal Data Set (MDS) dated [DATE], identified R2 had diagnoses which included paraplegia, chronic obstructive pulmonary disease (COPD), and respiratory failure. Further MDS identified required the use of oxygen (O2) therapy. R2's Order Summary dated 8/14/23, indicated R2 required O2 between 0-2 liters as needed to keep 02 saturation about 90% and nurse to check O2 tank prior to meals and change promptly if needed. R2's care plan dated 8/10/23, lacked evidence of a respiratory plan of care or any respiratory interventions which included: type of O2 delivery system, when to administer O2, equipment settings for prescribed flow rates, monitoring O2 levels and resident risks and monitoring for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• No harm found · C2023-11-08 · tag F0607 — failed to have anti-abuse policies — widespread
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility failed to ensure the posting of conspicuous signage of employee rights related to retaliation against the employee for reporting a suspected crime. This deficiency has the potential to affect all 74 residents currently residing in the facility. Findings include: During an observation on 11/8/23, a tour of the facility revealed the facility lacked signage of employee rights related to retaliation prohibition for reporting suspicions of a suspected crime posted within the facility. During an interview on 11/8/23 at 1:25 p.m., licensed practical nurse (LPN)-A reported that no retaliation was not addressed in the abuse policy online and staff reviewed it annually. Could not identify where employee rights related to retaliation were posted. During an interview on 11/8/23 at 1:30 p.m., director of program and operations verified employee rights related to retaliation prohibition for reporting suspicions of a suspected crime were not posted. During an interview on 11/8/23 at 2:00 p.m., administrator verified employee rights related to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 36 rows in the source record cover these 33 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

What families pay in MN