All citations for University Health Lakewood Medical Center

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to University Health Lakewood Medical Center

Last standard health inspection on record

August 22, 2025

Showing 1 to 25 of 45 citations

Immediate jeopardy to resident health or safety
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Isolated (one or a few residents). CMS level J.
Health citation F-0600, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of April 30, 2025. Found during a complaint inspection.
Past non-compliance: already corrected by the time of the inspection (April 18, 2025).
No harm, with potential for more than minimal harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Widespread (many residents). CMS level F.
Health citation F-0761, Pharmacy Service Deficiencies. Inspection of August 22, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (October 6, 2025).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
Widespread (many residents). CMS level F.
Health citation F-0880, Infection Control Deficiencies. Inspection of August 22, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (October 6, 2025).
No harm, with potential for more than minimal harm
Address subsistence needs for staff and patients.
Widespread (many residents). CMS level F.
Emergency preparedness citation E-0015, Emergency Preparedness Deficiencies. Inspection of August 22, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (October 6, 2025).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of August 22, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (October 6, 2025).
No harm, with potential for more than minimal harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Widespread (many residents). CMS level F.
Fire safety citation K-0354, Smoke Deficiencies. Inspection of August 22, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (October 6, 2025).
No harm, with potential for more than minimal harm
Provide a written emergency evacuation plan.
Widespread (many residents). CMS level F.
Fire safety citation K-0711, Miscellaneous Deficiencies. Inspection of August 22, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (October 6, 2025).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Widespread (many residents). CMS level F.
Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of August 22, 2025. Found during a standard inspection.
The home gave a date the problem would be corrected (October 6, 2025).
No harm, with potential for more than minimal harm
Have simulated fire drills held at unexpected times.
Widespread (many residents). CMS level F.
Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of November 14, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 3, 2024).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0345, Smoke Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (May 6, 2022).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
Widespread (many residents). CMS level F.
Fire safety citation K-0353, Smoke Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (March 25, 2022).
No harm, with potential for more than minimal harm
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Pattern (more than a few residents). CMS level E.
Health citation F-0557, Resident Rights Deficiencies. Inspection of March 20, 2026. Found during a complaint inspection.
Past non-compliance: already corrected by the time of the inspection.
No harm, with potential for more than minimal harm
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Pattern (more than a few residents). CMS level E.
Health citation F-0559, Resident Rights Deficiencies. Inspection of February 27, 2024. Found during a complaint inspection.
The home gave a date the problem would be corrected (April 8, 2024).
No harm, with potential for more than minimal harm
Have proper medical gas storage and administration areas.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of November 14, 2023. Found during a standard inspection.
The home gave a date the problem would be corrected (January 3, 2024).
No harm, with potential for more than minimal harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Pattern (more than a few residents). CMS level E.
Health citation F-0607, Freedom from Abuse, Neglect, and Exploitation Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (May 6, 2022).
No harm, with potential for more than minimal harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Pattern (more than a few residents). CMS level E.
Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (May 2, 2022).
No harm, with potential for more than minimal harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pattern (more than a few residents). CMS level E.
Health citation F-0761, Pharmacy Service Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (May 5, 2022).
No harm, with potential for more than minimal harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0222, Egress Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (April 15, 2022).
No harm, with potential for more than minimal harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0362, Smoke Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (March 25, 2022).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0363, Smoke Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (March 25, 2022).
No harm, with potential for more than minimal harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0374, Smoke Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (March 25, 2022).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (May 6, 2022).
No harm, with potential for more than minimal harm
Have restrictions on the use of portable space heaters.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0781, Miscellaneous Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (March 25, 2022).
No harm, with potential for more than minimal harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0914, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (May 6, 2022).
No harm, with potential for more than minimal harm
Ensure proper usage of power strips and extension cords.
Pattern (more than a few residents). CMS level E.
Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of March 25, 2022. Found during a standard inspection.
The home gave a date the problem would be corrected (March 25, 2022).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.