Pennsylvania Department of Health
LAKEWOOD REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LAKEWOOD REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are 143 surveys for this facility. Please select a date to view the survey results.

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LAKEWOOD REHABILITATION & HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on May 9, 2025, it was determined that Lakewood Rehabilitation and Healthcare Center corrected the federal deficiencies cited during the survey of April 2, 2025, under 42 CFR Part 483 Subpart B Requirements for Long Term Care but was out of compliance under the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 2 shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:15 on the night shift based on the facility's census.

May 3, 2025 - 4.03 nurse aides on the night shift, versus the required 5.87 for a census of 88.
May 4, 2025 - 3.13 nurse aides on the night shift, versus the required 5.93 for a census of 88.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on May 9, 2025, at 1:37 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.

Plan of Correction - To be completed: 05/27/2025

1. The facility cannot retroactively correct nurse aide staffing ratio.
2.NHA/designee will conduct an initial audit of the past two weeks' schedule to determine if nurse aide ratio is in compliance.
3. NHA/designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made.
4. NHA/designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for one shift out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following date the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:40 on the night shift based on the facility's census.

May 5, 2025 - 1.72 LPNs on the night shift, versus the required 2.23 for a census of 89.

On the above date mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on May 9, 2025, 1:37 PM, confirmed the facility had not met the required LPN to resident ratio on the above date.

Plan of Correction - To be completed: 05/27/2025

1. The facility cannot retroactively correct LPN staffing ratio.
2.NHA/designee will conduct an initial audit of the past two weeks' schedule to determine if LPN is in compliance.
3. NHA/designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made.
4. NHA/designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's staffing levels revealed that on the following date the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident:

May 3, 2025 - 3.19 direct care nursing hours per resident.

The facility's general nursing hours were below the minimum required level on the date noted above.

An interview with the Nursing Home Administrator on May 9, 2025, at 1:37 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 05/27/2025

1. The facility cannot retroactively correct staffing PPD.
2. NHA/designee will conduct an initial audit of the past two weeks scheduled to determine if PPD are in compliance.
3.NHA /designee will re-educate the scheduler on the proper PPD. The facility will hold labor meetings Monday-Friday to verify PPD is made.
4. NHA/designee will conduct random audits of facility PPD weekly for four weeks, then monthly for two months thereafter to verify proper PPD hours. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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