Inspection visit
Fire Safety inspection
Citations
22 citations recorded*CMS
This is a Fire Safety survey. CMS cites these findings under the Life Safety Code and Emergency Preparedness rules, a separate set from the health (F-tag) deficiencies. The codes and grading differ, so these do not link to the health violation pages.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0023GeneralS&S Fpotential for harm
Establish policies and procedures for medical documentation.
- 0020GeneralS&S Epotential for harm
Establish policies and procedures including evacuation.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
- 0030GeneralS&S Dpotential for harm
List the names and contact information of those in the facility.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0009GeneralS&S Fpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0042GeneralS&S Fpotential for harm
Meet the requirements of an integrated health system.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0364GeneralS&S Dpotential for harm
Install properly constructed windows in hallway walls or doors.
- 0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0711GeneralS&S Fpotential for harm
Provide a written emergency evacuation plan.
- 0761GeneralS&S Fpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0001GeneralS&S Fpotential for harm
Establish an Emergency Preparedness Program (EP).
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0354GeneralS&S Fpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
FAQ · About this visit
Common questions about this visit
What happened during the September 19, 2022 survey of THE OAKS AT LAKEWOOD?
This was a inspection survey of THE OAKS AT LAKEWOOD on September 19, 2022. The surveyor cited 22 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE OAKS AT LAKEWOOD on September 19, 2022?
Yes, 22 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Establish policies and procedures for medical documentation."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.