Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakewood Health System during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of falls was not adequately supervised, leading to an unwitnessed fall and a fracture. Despite being on a care plan requiring hourly safety checks and toileting every two hours, staff failed to monitor the resident properly. The resident was found in a sleep study room with a fracture, requiring surgical intervention. Staff interviews revealed the care plan was not followed due to workload, and documentation was incomplete.
Failure to Prevent Resident Wandering and Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent wandering and falls for a resident, resulting in actual harm. The resident, who had a history of cognitive impairment, dementia, and recurrent falls, was at high risk for falls and required substantial assistance with daily activities. Despite being on a care plan that included hourly safety checks and toileting every two hours, the resident was not adequately monitored, leading to an unwitnessed fall that resulted in a fracture of the right leg. On the day of the incident, the resident was last seen in the dining room at 6:15 p.m. and was supposed to be taken to a common area for distraction, but this intervention was not followed. The resident was not located for several hours, and staff failed to document hourly safety checks and toileting as required by the care plan. The resident was eventually found in a sleep study room, having fallen and sustained a fracture, which required surgical intervention. Interviews with staff revealed that the care plan was not followed due to being busy with other tasks, and there was a lack of proper documentation and monitoring. The resident's elopement risk was not adequately assessed, and the care plan was not updated to reflect the need for increased supervision. The failure to adhere to the care plan and provide necessary supervision directly contributed to the resident's fall and injury.
Removal Plan
- The facility implemented corrective action and was determined to be in compliance.
- Both staff involved were immediately removed from the schedule and disciplinary actions were completed for R1's care not followed.
- Audits were put into place for close monitoring of care and care plans.
- R1 would be assessed for a wander guard or memory care placement due to new recent wandering behavior.
- Education was provided to the staff directly involved in incident; NA-A, PCA, and additional education was provided to NA's while audits were completed by the staff nurse every shift.
- Audits continued so that all staff were monitored for frequent checks and residents toileted according to their care plan.
- Expectation for staff would be the care plan followed in its entirety and was made very clear during audits.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Staples
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fair Oaks Lodge | 15.8 mi | — | 7 | 0 |
| Central Todd County Care Center | 19.8 mi | — | 5 | 0 |
| Cura Of Long Prairie | 27.9 mi | — | 1 | 0 |
| Good Samaritan Society - Woodland | 28.1 mi | — | 1 | 0 |
| Good Samaritan Society - Bethany | 28.6 mi | — | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.