Inspection visit
Inspection
Citations
34 citations recorded*CMS
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.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F637 - Within 14 days after the facility determines, or should have determined,
Assess the resident when there is a significant change in condition
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0020GeneralS&S Epotential for harm
Establish policies and procedures including evacuation.
- 0022GeneralS&S Fpotential for harm
Establish policies and procedures for sheltering.
- 0023GeneralS&S Fpotential for harm
Establish policies and procedures for medical documentation.
- 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.
- 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.
- 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.
- 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.
- 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.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
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 34 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE OAKS AT LAKEWOOD on September 19, 2022?
Yes, 34 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before tran..."
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.