summary: Plan of Correction - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES eo

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

346229 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE

WILKESBORO, NC 28697

LAKEWOOD

ayo | SUMMARY STATEMENT OF DEFICIENCIES | oD PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX | (EACH CORRECTIVE ACTION SHOULD BE | COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG CROSS-REFERENCED TO THE APPROPRIATE Dare

DEFICIENCY)

W 249 | PROGRAM IMPLEMENTATION W 249)
CFR(s): 483.440(d)(1)

As soon as the interdisciplinary team has W 249 (A)(B)(C) & (D)
formulated a client's individual Program plan, | The QIDP will meet with the Clinical
| each client must receive a continuous active team to determine if changes are

treatment program consisting of needed
interventions and services in sufficient number needed to the Behavior Support Plan

| and frequency to support the achievement of the _ | Of client #4 and #2. Following any
objectives identified in the individual program | necessary changes QIDP will in-service
plan. | staff on client #4 and #2’s Behavior

Support Plans. QIDP will in-service all

|
| staff on client #5’s mealtime

| This STANDARD is not met as evidenced by: guidelines. QIDP will in-service all

| Based on observations, record review and | | staff on the use of client #1's adaptive

i interviews, the facility failed to ensure that a | PT equipment. Clinical team will
continuous active treatment programs consisting monitor to ensure above active |

of needed behavioral interventions and adaptive

equipment that were implemented as identified in | treatment occurs by 2x a week

| the person-centered plan (PCP) for 4 of 4 interaction Assessments for 1 month.
| Sampled clients (#1, #2, #4, #5). The findings are: | | In the future the clinical team will
| A. The facility failed to f low Geran 1 | ensure active treatment occurs by |
e facility failed to follow Vvioral | - Siigsinesnibndhh ity A |
interventions for client #4 relative to target a ar y Quality Assurance |
| behaviors. For example: ?
| Observations throughout the recertification survey | | By: September 12th, 2025

from 7/15/25-7/16/25 revealed client #4 to pace
| throughout the facility while sporadically kicking |
the wall. Further observations reveal client #4 to
| make growling noises and make attempts to bite |
| at surveyors and staff. Observations did not |
reveal staff to address or redirect client #4 from RECEIVED
kicking and biting. |

| Review of the record for client #4 on 7/16/25 | |
| revealed a PCP dated 6/10/25 which indicated | | ; ct
| the client has the following diagnoses: Tourette's | JHSR-MH Licensure Se

| Syndrome, /DD moderate, unspecified Psychotic |

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

% : 1D "93S
Any deficiency statement ing with an asterisk (*) denote deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients~ (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. {f deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

DEPARTMENT OF HEALTH AND HUMAN SERVICES rR ORM AREER

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0394

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: MS oe

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G229 8. WING

07/46/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE

WILKESBORO, NC 28697

xan | SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
{ DEFICIENCY)

LAKEWOOD

]
w 249! Continued From page 1 ; W249)
Disorder, Obsessive Compulsive Disorder (OCD), | |
neurogenic bladder, GERD, Helicobacter Pylori | |
| infection, Vitamin D3 deficiency, Hyperopia, |
Astigmatism, seasonal allergies, and history of
Seizure Disorder.

| Subsequent review of the record for client #4
| revealed a behavioral support plan (BSP) dated
2/10/25 which indicated the client has the | | |
following target behaviors: resistance/refusal,
| physical and verbal aggression, property
| destruction, skin picking, psychotic behavior, |
| bossing others, and other obsessive-compulsive |
acts. Further review of the record for client #4 | |
| tevealed the foliowing interventions for physical |
| aggression: “if she starts kicking/hitting the wall, | |
| direct her to her room, then offer her a foam bat | |
to use instead of her feet, arm, or hand. Support
her in releasing the aggression.Wait until she is | |
| calm for at least 5 minutes prior to encouraging | |
| her to return to her regularly scheduled activity".
| Continued review of the 2/2025 BSP revealed if
| the client “gets excited and bites someone during |
| a greeting, tell her to STOP and block her action | |
| with your body or hand. Then demonstrate and
, verbally instruct her the proper way to greet |
| someone by shaking their hand. Give her an | | |
| opportunity to shake the person's hands and your | |
' hand using correct social techniques. Praise her |
| for appropriate social behavior".

Interview with the behavioral specialist on 7/16/25 | |

revealed client #4 often exhibits these behaviors | |

| and they are how the client communicates j

| affection. Further interview with the behavioral |

| specialist revealed staff should utilize the | |

| interventions if the client's behaviors become | | |
extreme. |

If continuation sheet Page 2 of 7

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:BWIV11 Facility ID: $22099

DEPARTMENT OF HEALTH AND HUMAN SERVICES ae

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

346229 B. WING

07/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, 2IP CODE
LAKEWooD 554 RIDGE LANE
WILKESBORO, NC 28697
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION | os)
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETION

TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CO CROSS-REFERENCED TO THE APPROPRIATE DATE
| | DEFICIENCY)

| Continued From page 2 W 249;
| Interview with the qualified intellectual disabilities | |
professional (QIDP) on 7/16/25 verified that all of
the behavioral interventions for client #4 are

current. Further interview with the QIDP verified | |
Staff have been trained to utilize the BSP for client | |
#4's target behaviors as prescribed. j

| B. The facility failed to follow mealtime guidelines i
as prescribed for client #5. For example: | |

Morning observations on 7/16/25 at 8:05AM | |
| reveled client #5 to sit at the dining table |
| participating in the breakfast meal. Further | |

observations revealed client #5 to eat at a fast |
| pace with excessive spillage on the table and |
| floor. Continued observations revealed client #5 |
to overstuff her mouth several times during the |
| breakfast meal while talking to staff. Observations | |
| did not reveal staff to redirect client #5 or prompt | |
| the client to slow her rate of eating as prescribed.

|
| Review of the record for client #5 on 7/16/25 | |
revealed a PCP dated 1/7/25 and occupational |
| therapy (OT) Assessment dated 11/25/24. Further |
review of the 7/2025 PCP revealed client #5 has | |
mealtime guidelines that must be followed to slow |
| her rate of eating. Continued review of the 7/2025 | |
PCP revealed the following interventions relative | |
to meaitimes: “after two verbal prompts and/or =| |
| partial physical prompts to siow rate of eating, |
| staff should move her plate to the center of the
table to give the client a chance to chew and
swallow her current bite. Then the plate can be
| reintroduced, and she would again be prompted
two times before the plate would be removed and |
prompt sequence will be repeated until her meal |
| is finished”. | |

| Interview with the QIDP on 7/16/25 verified the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:BWIV11 Facility ID; 322099 If continuation sheet Page 3 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES PR RORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X3) DATI ry
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: h COMPLE,

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

346229 B. WING

07/16/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

LAKEWOOD

(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES iD | PROVIDER'S PLAN OF CORRECTION 5)
PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | TAG | CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

| Continued From page 3
mealtime guidelines for client #5 are current.
Further interview with the QIDP revealed staff |
have received training on meaitime guidelines for |
client #5. Continued interview with the QIDP |
verified staff should follow client #5's mealtime | |
guidelines as prescribed.

| C. The facility failed to provide and utilized client
| #1's gait belt as prescribed.

Observation at the home on 7/15/25 from 4:40
PM-5:10 PM revealed client #1 was observed not |
wearing her gait belt. Further observation

| revealed client #1 to participate in preparing the
dinner meal and her gait was unsteady (X2) while
attempting to retrieve items from the kitchen
pantry.
| Observation at the home on 7/16/25 from 7:10 |
AM-8:20 AM revealed client #1 was observed not
wearing her gait belt. Further observation |
revealed client #1 fo participate in the breakfast |
| meal and she cleaned the dining room table | |
| afterwards; her gait was unsteady (X3). |

Review of the record on 7/15/25 for client #1 j |
| revealed a PCP dated 8/1/24 which identified the | |
| following adaptive equipment: walker, wheeled | |
| walker, gait belt, buckle buddy, heimet, | |
| eyeglasses. Further review of the PCP indicated | |
client #1's gait belt and walker to be always }
| utilized per PT evaluation ( if client #1 does not

| want to use her walker, staff need to ensure that
they are supporting her in mobility by holding on
to her gait belt while she is up and mobile).

| Interview on 7/16/25 with the QIDP confirmed
client #1 should have been wearing her gait belt | |
_ She is up and mobile.

FORM CMS-2567(02-99) Previous Versions Obsolete Event (D: BWIV11 Facility 10: 822099 if continuation sheet Page 4 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES PRPORM ARE

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G229 B.WING ___

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
LAKEWOOD 554 RIDGE LANE
WILKESBORO, NC 28697

(x4)i0 | SUMMARY STATEMENT OF DEFICIENCIES ] 1D PROVIDER'S PLAN OF CORRECTION | 16
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG | —_- REGULATORY OR LSC IDENTIFYING INFORMATION) |} TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

| Continued From page 4

| D. The facility failed to follow behavioral | |
| interventions for client #2 relative to target \ |
behaviors. For example: | |

| Observations throughout the recertification survey
| from 7/15/25-7/16/25 revealed client #2 to follow i
Surveyor throughout the facility while interlocking
| her arm with surveyors' arm and attempting to |
| kiss surveyor (X3) in the face, Further | | |
| observations did not reveal staff to address or i

| redirect client #2 attempts at kissing and holding |
on to the surveyor,

| Review of the record on 7/15/25 for client #2
revealed a behavioral support plan (BSP) dated |
3/3/25 which indicated client #2 has the following |
target behaviors: Cooperation, property
destruction, tantrums, inappropriate social
behavior (inappropriate acts that violate the
Personal space of others such as trying to kiss |
others, playing with and/or smelling hair of others,
or trying to hug others), taking others belongings,
| and elopement. Further review of the record for |
| client #2 revealed the following interventions for |
inappropriate social behavior: "if client #2 is
observed engaging in inappropriate or unsafe
| behavior, staff should immediately redirect her to |
| a scheduled task, offering support and hand over i
| hand prompts as needed".

Interview with the qualified intellectual disabilities |
professional (QIDP) on 7/16/25 verified that all of |
the prevention guidelines for interaction for client |
| #2 are current. Further interview with the QIDP

| verified staff have been trained to utilize the BSP
for client #2's target behaviors as prescribed.
Continued interview with the QIDP verified staff
should foliow client #2's prevention guidelines as

FORM CMS-2567(02-99) Previous Versions Obsolete Event (D:BWIV11 Facility ID: 922099 If continuation sheet Page 5 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES eR ORM APPRONED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

(X2) MULTIPLE CONSTRUCTION
A, BUILDING

34G229 B. WING

07/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE

WILKESBORO, NC 28697

LAKEWOOD

(4) iD SUMMARY STATEMENT OF DEFICIENCIES | 1D PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE |
TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG | CROSS-REFERENCED TO THE APPROPRIATE. DATE

DEFICIENCY)

Continued From page 5
written. |
W 488 | DINING AREAS AND SERVICE W 488;
| CFR(s): 483.480(d)(4) | W 488 (A)(B)
| ram

The facility must assure that each client eats in a | a atDP “il a Propet Use ot |
manner consistent with his or her developmental | | 2captive equipment during dining as |
‘level, reflected in client #3 and client #5’s
This STANDARD is not met as evidenced by: PCP. Team will monitor for use with
Pinar on ohecvations and ere staff a 2x a week Mealtime Assessments for

iled to provide appropriate dining utensils to 2 o F
banned clients (a1, #5} io anette Hien ¥a Wak ee in the flere the tesarn wil
at their developmental level. The findings are: ure appropriate use of mealtime
adaptive equipment by ongoing

A. The facility failed to provide appropriate dining | | Monthly Quality Assurance
utensils to client #3 relative to a dycem mat. For | assessments.
| example: | |

By: September 12th, 2025

| Observations on 7/16/25 at 8:05AM revealed |
| client #3 to sit at the dining room table to prepare |
| for the breakfast meal. Further observation |
revealed staff to place client #3's plate and dycem |
mat on top of a piece of paper towel. Continued |
observation revealed client #3 to consume the | |
breakfast meal as staff would occasionally |
re-adjust the client's plate on top of the paper |
towel,

i |
Interview with staff E on 6/25/25 revealed staff | |
| place the clients' plates on top of the shirt
protector to minimize spillage during mealtimes. |
Interview with the qualified intellectual disabilities |
professional (QIDP) on 7/16/25 revealed staff
| should not have placed the clients’ plates on top
of a piece of paper towel during mealtimes. |
| Further interview with the QIDP revealed staff |
| have been trained to provide dignity and respect | {
to clients and use the clients' prescribed adaptive
equipment during mealtimes. {

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BWiv11 Facility 1D: 322099 If continuation sheet Page 6 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES amas

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: Nena

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G229 B. WING

07/46/2025

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

(x4y1D | SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION | (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX | (EACH CORRECTIVE ACTION SHOULD BE ‘COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG | (CROSS-REFERENCED TO THE APPROPRIATE OATE

DEFICIENCY)

|
Continued From page 6

B. The facility failed to instruct client #5 to use her |
adaptive equipment during meaitimes. For | |
example: | |

|

|
Observations on 7/16/25 at 8:05AM revealed | | |
client #5 to enter the kitchen to prepare her plate | |
for the breakfast meal. Observations revealed
Staff to place a table setting to include a maroon
spoon and regular spoon for client #5. Further
observation revealed client #5 to sit at the dining
| fable and participate in the breakfast meal without | |
using her maroon spoon. At no point during the |
observation did staff prompt client #5 to use her | |
maroon spoon during the breakfast meal.

| Review of the record for client #5 on 7/16/25
revealed a PCP dated 1/7/25 and OT assessment
dated 11/25/24 which indicated the client uses a

| maroon spoon during mealtimes due to rate of | |
eating, scooping too large bites and overstuffing
her mouth when eating. |

Interview with the QIDP on 7/16/25 revealed staff
| should have prompted client #5 to use her |
| maroon spoon during mealtimes in order to slow |

her rate of eating and prevent the client from |
overstuffing her mouth, Further interview with the |
QIDP verified client #5’s adaptive equipment and |
| interventions were current. Continued interview |
with the QIDP verified staff have been trained to |
provide and instruct clients to use their adaptive |
equipment during mealtimes as prescribed. |

|

if continuation sheet Page 7 of 7

FORM CMS-2567(02-99) Previous Versions Obsolete Event I0:BWIV11 Facility ID: 922099

inspection_type: MHLCS Annual


state: NC

facility_name: Lakewood

summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

PRINTED: 07/25/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING 07/16/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(x8)
COMPLETION
DATE

W 249 PROGRAM IMPLEMENTATION
CFR(s): 483.440(d)(1)

As soon as the interdisciplinary team has
formulated a client's individual program plan,
each client must receive a continuous active
treatment program consisting of needed
interventions and services in sufficient number
and frequency to support the achievement of the
objectives identified in the individual program
plan.

This STANDARD is not met as evidenced by:
Based on observations, record review and
interviews, the facility failed to ensure that a
continuous active treatment programs consisting
of needed behavioral interventions and adaptive
equipment that were implemented as identified in
the person-centered plan (PCP) for 4 of 4
sampled clients (#1, #2, #4, #5). The findings are:

A. The facility failed to follow behavioral
interventions for client #4 relative to target
behaviors. For example:

Observations throughout the recertification survey
from 7/15/25-7/16/25 revealed client #4 to pace
throughout the facility while sporadically kicking
the wall. Further observations reveal client #4 to
make growling noises and make attempts to bite
at surveyors and staff. Observations did not
reveal staff to address or redirect client #4 from
kicking and biting.

Review of the record for client #4 on 7/16/25
revealed a PCP dated 6/10/25 which indicated
the client has the following diagnoses: Tourette's
Syndrome, I/DD moderate, unspecified Psychotic

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

W 249

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BWIV11

Facility ID: 922099 If continuation sheet Page 1 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

PRINTED: 07/25/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING
STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE

07/16/2025

Disorder, Obsessive Compulsive Disorder (OCD),
neurogenic bladder, GERD, Helicobacter Pylori
infection, Vitamin D3 deficiency, Hyperopia,
Astigmatism, seasonal allergies, and history of
Seizure Disorder.

Subsequent review of the record for client #4
revealed a behavioral support plan (BSP) dated
2/10/25 which indicated the client has the
following target behaviors: resistance/refusal,
physical and verbal aggression, property
destruction, skin picking, psychotic behavior,
bossing others, and other obsessive-compulsive
acts. Further review of the record for client #4
revealed the following interventions for physical
aggression: "if she starts kicking/hitting the wall,
direct her to her room, then offer her a foam bat
to use instead of her feet, arm, or hand. Support
her in releasing the aggression.Wait until she is
calm for at least 5 minutes prior to encouraging
her to return to her regularly scheduled activity".
Continued review of the 2/2025 BSP revealed if
the client "gets excited and bites someone during
a greeting, tell her to STOP and block her action
with your body or hand. Then demonstrate and
verbally instruct her the proper way to greet
someone by shaking their hand. Give her an
opportunity to shake the person's hands and your
hand using correct social techniques. Praise her
for appropriate social behavior".

Interview with the behavioral specialist on 7/16/25
revealed client #4 often exhibits these behaviors
and they are how the client communicates
affection. Further interview with the behavioral
specialist revealed staff should utilize the
interventions if the client's behaviors become
extreme.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BWIV11

LAKEWOOD
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 249 Continued From page 1 W 249

Facility ID: 922099 If continuation sheet Page 2 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

PRINTED: 07/25/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING 07/16/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE

Interview with the qualified intellectual disabilities
professional (QIDP) on 7/16/25 verified that all of
the behavioral interventions for client #4 are
current. Further interview with the QIDP verified
staff have been trained to utilize the BSP for client
#4's target behaviors as prescribed.

B. The facility failed to follow mealtime guidelines
as prescribed for client #5. For example:

Morning observations on 7/16/25 at 8:05AM
reveled client #5 to sit at the dining table
participating in the breakfast meal. Further
observations revealed client #5 to eat at a fast
pace with excessive spillage on the table and
loor. Continued observations revealed client #5

(o overstuff her mouth several times during the
breakfast meal while talking to staff. Observations
did not reveal staff to redirect client #5 or prompt
he client to slow her rate of eating as prescribed.

Review of the record for client #5 on 7/16/25
revealed a PCP dated 1/7/25 and occupational
herapy (OT) Assessment dated 11/25/24. Further
review of the 7/2025 PCP revealed client #5 has
mealtime guidelines that must be followed to slow
her rate of eating. Continued review of the 7/2025
PCP revealed the following interventions relative
io mealtimes: "after two verbal prompts and/or
partial physical prompts to slow rate of eating,
staff should move her plate to the center of the
able to give the client a chance to chew and
swallow her current bite. Then the plate can be
reintroduced, and she would again be prompted
wo times before the plate would be removed and
prompt sequence will be repeated until her meal
is finished".

nterview with the QIDP on 7/16/25 verified the

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: BWIV11

LAKEWOOD
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 249 Continued From page 2 W 249

Facility ID: 922099 If continuation sheet Page 3 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

PRINTED: 07/25/2025
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

mealtime guidelines for client #5 are current.
Further interview with the QIDP revealed staff
have received training on mealtime guidelines for
client #5. Continued interview with the QIDP
verified staff should follow client #5's mealtime
guidelines as prescribed.

C. The facility failed to provide and utilized client
#1's gait belt as prescribed.

Observation at the home on 7/15/25 from 4:40
PM-5:10 PM revealed client #1 was observed not
wearing her gait belt. Further observation
revealed client #1 to participate in preparing the
dinner meal and her gait was unsteady (X2) while
attempting to retrieve items from the kitchen
pantry.

Observation at the home on 7/16/25 from 7:10
AM-8:20 AM revealed client #1 was observed not
wearing her gait belt. Further observation
revealed client #1 to participate in the breakfast
meal and she cleaned the dining room table
afterwards; her gait was unsteady (X3).

Review of the record on 7/15/25 for client #1
revealed a PCP dated 8/1/24 which identified the
following adaptive equipment: walker, wheeled
walker, gait belt, buckle buddy, helmet,
eyeglasses. Further review of the PCP indicated
client #1's gait belt and walker to be always
utilized per PT evaluation ( if client #1 does not
want to use her walker, staff need to ensure that
they are supporting her in mobility by holding on
to her gait belt while she is up and mobile).

Interview on 7/16/25 with the QIDP confirmed
client #1 should have been wearing her gait belt
she is up and mobile.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BWIV11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
346229 B. WING 07/16/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
LAKEWOOD 554 RIDGE LANE
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 249 Continued From page 3 W 249

Facility ID: 922099 If continuation sheet Page 4 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

PRINTED: 07/25/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING 07/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE

D. The facility failed to follow behavioral
interventions for client #2 relative to target
behaviors. For example:

Observations throughout the recertification survey
from 7/15/25-7/16/25 revealed client #2 to follow
surveyor throughout the facility while interlocking
her arm with surveyors' arm and attempting to
kiss surveyor (X3) in the face. Further
observations did not reveal staff to address or
redirect client #2 attempts at kissing and holding
on to the surveyor.

Review of the record on 7/15/25 for client #2
revealed a behavioral support plan (BSP) dated
3/3/25 which indicated client #2 has the following
target behaviors: Cooperation, property
destruction, tantrums, inappropriate social
behavior (inappropriate acts that violate the
personal space of others such as trying to kiss
others, playing with and/or smelling hair of others,
or trying to hug others), taking others belongings,
and elopement. Further review of the record for
client #2 revealed the following interventions for
inappropriate social behavior: "if client #2 is
observed engaging in inappropriate or unsafe
behavior, staff should immediately redirect her to
a scheduled task, offering support and hand over
hand prompts as needed".

Interview with the qualified intellectual disabilities
professional (QIDP) on 7/16/25 verified that all of
the prevention guidelines for interaction for client
#2 are current. Further interview with the QIDP
verified staff have been trained to utilize the BSP
for client #2's target behaviors as prescribed.
Continued interview with the QIDP verified staff
should follow client #2's prevention guidelines as

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BWIV11

LAKEWOOD
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 249 Continued From page 4 W 249

Facility ID: 922099 If continuation sheet Page 5 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

PRINTED: 07/25/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING 07/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE

CFR(s): 483.480(d)(4)

The facility must assure that each client eats in a
manner consistent with his or her developmental
level.

This STANDARD is not met as evidenced by:
Based on observations and interviews, staff
failed to provide appropriate dining utensils to 2 of
4 sampled clients (#1, #3) to enable them to eat
at their developmental level. The findings are:

A. The facility failed to provide appropriate dining
utensils to client #3 relative to a dycem mat. For
example:

Observations on 7/16/25 at 8:05AM revealed
client #3 to sit at the dining room table to prepare
for the breakfast meal. Further observation
revealed staff to place client #3's plate and dycem
mat on top of a piece of paper towel. Continued
observation revealed client #3 to consume the
breakfast meal as staff would occasionally
re-adjust the client's plate on top of the paper
iowel.

nterview with staff E on 6/25/25 revealed staff
place the clients' plates on top of the shirt
protector to minimize spillage during mealtimes.
nterview with the qualified intellectual disabilities
professional (QIDP) on 7/16/25 revealed staff
should not have placed the clients’ plates on top
of a piece of paper towel during mealtimes.
Further interview with the QIDP revealed staff
have been trained to provide dignity and respect
o clients and use the clients’ prescribed adaptive
equipment during mealtimes.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BWIV11

LAKEWOOD
WILKESBORO, NC 28697

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
W 249 Continued From page 5 W 249
written.

W 488 DINING AREAS AND SERVICE W 488

Facility ID: 922099 If continuation sheet Page 6 of 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

PRINTED: 07/25/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING 07/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE

B. The facility failed to instruct client #5 to use her
adaptive equipment during mealtimes. For
example:

Observations on 7/16/25 at 8:05AM revealed
client #5 to enter the kitchen to prepare her plate
for the breakfast meal. Observations revealed
staff to place a table setting to include a maroon
spoon and regular spoon for client #5. Further
observation revealed client #5 to sit at the dining
table and participate in the breakfast meal without
using her maroon spoon. At no point during the
observation did staff prompt client #5 to use her
maroon spoon during the breakfast meal.

Review of the record for client #5 on 7/16/25
revealed a PCP dated 1/7/25 and OT assessment
dated 11/25/24 which indicated the client uses a
maroon spoon during mealtimes due to rate of
eating, scooping too large bites and overstuffing
her mouth when eating.

Interview with the QIDP on 7/16/25 revealed staff
should have prompted client #5 to use her
maroon spoon during mealtimes in order to slow
her rate of eating and prevent the client from
overstuffing her mouth. Further interview with the
QIDP verified client #5's adaptive equipment and
interventions were current. Continued interview
with the QIDP verified staff have been trained to
provide and instruct clients to use their adaptive
equipment during mealtimes as prescribed.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BWIV11

LAKEWOOD
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 488 Continued From page 6 W 488

Facility ID: 922099 If continuation sheet Page 7 of 7

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

PRINTED: 02/12/2025
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
346229 B. WING 02/07/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
LAKEWOOD 554 RIDGE LANE
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000. INITIAL COMMENTS W 000
Acomplaint survey was completed on 2/7/25 for
intake #NC00226245. The allegation was
unsubstantiated. No deficiencies were cited.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:61DD11

Facility ID: 922099 If continuation sheet Page 1 of 1

inspection_type: MHLCS Complaint


summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

PRINTED: 11/04/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

R
11/04/2024

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS W 000
Arevisit was conducted on 11/4/2024 for all
previous deficiencies cited on 7/31/2024. All
deficiencies were corrected and no new
non-compliance was found. The facility is in
compliance with all regulations surveyed.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: WTJH12

Facility ID: 922099 If continuation sheet Page 1 of 1

inspection_type: MHLCS Follow-up


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

07/31/2024
STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE
WILKESBORO, NC 28697

ID PROVIDER'S PLAN OF CORRECTION (x8)

PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

E 039 | EP Testing Requirements
CFR(s): 483.475(d)(2)

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2),
§460.84(d)(2), §482.15(d)(2), §483.73(d)(2),

§483.475(d)(2), §484.102(d)(2), §485.68(d)(
§485.542(d)(2), §485.625(d)(2), §485.727(d
§485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

S

2),

*[For ASCs at §416.54, CORFs at §485.68, REHs
at §485.542, OPO, "Organizations" under
§485.727, CMHCs at §485.920, RHCs/FQHCs at
§491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises
to test the emergency plan annually. The [facility]
must do all of the following:

(i) Participate in a full-scale exercise that is
community-based every 2 years; or
(A) When a community-based exercise is not
accessible, conduct a facility-based functional
exercise every 2 years; or

(B) If the [facility] experiences an actual
natural or man-made emergency that requires
activation of the emergency plan, the [facility] is
exempt from engaging in its next required
community-based or individual, facility-based
functional exercise following the onset of the
actual event.
(ii) Conduct an additional exercise at least every 2
years, opposite the year the full-scale or
functional exercise under paragraph (d)(2)(i) of
this section is conducted, that may include, but is
not limited to the following:
(A) Asecond full-scale exercise that is
community-based or individual, facility-based
functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

E 039

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: WTJH11

Facility ID: 922099 If continuation sheet Page 1 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

PRINTED: 08/01/2024

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

(X3) DATE SURVEY

COMPLETED

07/31/2024

a facilitator and includes a group discussion using
a narrated, clinically-relevant emergency
scenario, and a set of problem statements,
directed messages, or prepared questions
designed to challenge an emergency plan.

(iii) Analyze the [facility's] response to and
maintain documentation of all drills, tabletop
exercises, and emergency events, and revise the
[facility's] emergency plan, as needed.

*[For Hospices at 418. 113(d):]

(2) Testing for hospices that provide care in the
patient's home. The hospice must conduct
exercises to test the emergency plan at least
annually. The hospice must do the following:

(i) Participate in a full-scale exercise that is
community based every 2 years; or

(A) When a community based exercise is not
accessible, conduct an individual facility based
functional exercise every 2 years; or

(B) If the hospice experiences a natural or
man-made emergency that requires activation of
the emergency plan, the hospital is exempt from
engaging in its next required full scale
community-based exercise or individual
facility-based functional exercise following the
onset of the emergency event.

(ii) Conduct an additional exercise every 2 years,
opposite the year the full-scale or functional
exercise under paragraph (d)(2)(i) of this section
is conducted, that may include, but is not limited
to the following:

(A) Asecond full-scale exercise that is
community-based or a facility based functional
exercise; or

(B) Amock disaster drill; or

(C) A tabletop exercise or workshop that is led by
a facilitator and includes a group discussion using

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 039) Continued From page 1 E 039

Facility ID: 922099

If continuation sheet Page 2 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

PRINTED: 08/01/2024

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

(X3) DATE SURVEY

COMPLETED

07/31/2024

a narrated, clinically-relevant emergency

scenario, and a set of problem statements,
directed messages, or prepared questions
designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient
care directly. The hospice must conduct
exercises to test the emergency plan twice per
year. The hospice must do the following:

(i) Participate in an annual full-scale exercise that
is community-based; or

(A) When a community-based exercise is not
accessible, conduct an annual individual
facility-based functional exercise; or

(B) If the hospice experiences a natural or
man-made emergency that requires activation of
the emergency plan, the hospice is exempt from
engaging in its next required full-scale community
based or facility-based functional exercise
following the onset of the emergency event.

(ii) Conduct an additional annual exercise that
may include, but is not limited to the following:
(A) Asecond full-scale exercise that is
community-based or a facility based functional
exercise; or

(B) Amock disaster drill; or

(C) A tabletop exercise or workshop led by a
facilitator that includes a group discussion using a
narrated, clinically-relevant emergency scenario,
and a set of problem statements, directed
messages, or prepared questions designed to
challenge an emergency plan.

(iii) Analyze the hospice's response to and
maintain documentation of all drills, tabletop
exercises, and emergency events and revise the
hospice's emergency plan, as needed.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 039] Continued From page 2 E 039

Facility ID: 922099

If continuation sheet Page 3 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2024

*[For PRFTs at §441.184(d), Hospitals at
§482.15(d), CAHs at §485.625(d):]

(2) Testing. The [PRTF, Hospital, CAH] must
conduct exercises to test the emergency plan
twice per year. The [PRTF, Hospital, CAH] must
do the following:

(i) Participate in an annual full-scale exercise that
is community-based; or
(A) When a community-based exercise is not
accessible, conduct an annual individual,
facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an
actual natural or man-made emergency that
requires activation of the emergency plan, the
[facility] is exempt from engaging in its next
required full-scale community based or individual,
facility-based functional exercise following the
onset of the emergency event.

(ii) Conduct an [additional] annual exercise or
and that may include, but is not limited to the
following:

(A) Asecond full-scale exercise that is
community-based or individual, a facility-based
functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop that is
led by a facilitator and includes a group
discussion, using a narrated, clinically-relevant
emergency scenario, and a set of problem
statements, directed messages, or prepared
questions designed to challenge an emergency
plan.

(iii) Analyze the [facility's] response to and
maintain documentation of all drills, tabletop
exercises, and emergency events and revise the
[facility's] emergency plan, as needed.

*[For PACE at §460.84(d):]

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 039] Continued From page 3 E 039

Facility ID: 922099

If continuation sheet Page 4 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2024

(2) Testing. The PACE organization must conduct
exercises to test the emergency plan at least
annually. The PACE organization must do the
following:

(i) Participate in an annual full-scale exercise that
is community-based; or

(A) When a community-based exercise is not
accessible, conduct an annual individual,
facility-based functional exercise; or

(B) If the PACE experiences an actual natural or
man-made emergency that requires activation of
the emergency plan, the PACE is exempt from
engaging in its next required full-scale community
based or individual, facility-based functional
exercise following the onset of the emergency
event.

(ii) Conduct an additional exercise every 2
years opposite the year the full-scale or functional
exercise under paragraph (d)(2)(i) of this section
is conducted that may include, but is not limited to
the following:

(A) Asecond full-scale exercise that is
community-based or individual, a facility based
functional exercise; or

(B) Amock disaster drill; or

(C) A tabletop exercise or workshop that is led by
a facilitator and includes a group discussion,
using a narrated, clinically-relevant emergency
scenario, and a set of problem statements,
directed messages, or prepared questions
designed to challenge an emergency plan.

(iii) Analyze the PACE's response to and
maintain documentation of all drills, tabletop
exercises, and emergency events and revise the
PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

Facility ID: 922099

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 039] Continued From page 4 E 039

If continuation sheet Page 5 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2024

test the emergency plan at least twice per year,
including unannounced staff drills using the
emergency procedures. The [LTC facility,
ICF/IID] must do the following:

(i) Participate in an annual full-scale exercise that
is community-based; or

(A) When a community-based exercise is not
accessible, conduct an annual individual,
facility-based functional exercise.

(B) If the [LTC facility] facility experiences an
actual natural or man-made emergency that
requires activation of the emergency plan, the
LTC facility is exempt from engaging its next
required a full-scale community-based or
individual, facility-based functional exercise
following the onset of the emergency event.

(ii) Conduct an additional annual exercise that
may include, but is not limited to the following:

(A) Asecond full-scale exercise that is
community-based or an individual, facility based
functional exercise; or

(B) Amock disaster drill; or

(C) A tabletop exercise or workshop that is led by
a facilitator includes a group discussion, using a
narrated, clinically-relevant emergency scenario,
and a set of problem statements, directed
messages, or prepared questions designed to
challenge an emergency plan.

(iii) Analyze the [LTC facility] facility's response to
and maintain documentation of all drills, tabletop
exercises, and emergency events, and revise the
[LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:

(2) Testing. The ICF/IID must conduct exercises
to test the emergency plan at least twice per year.
The ICF/IID must do the following:

(i) Participate in an annual full-scale exercise that

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 039) Continued From page 5 E 039

Facility ID: 922099

If continuation sheet Page 6 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 039] Continued From page 6 E 039

is community-based; or

(A) When a community-based exercise is not
accessible, conduct an annual individual,
facility-based functional exercise; or.

(B) If the ICF/IID experiences an actual natural or
man-made emergency that requires activation of
the emergency plan, the ICF/IID is exempt from
engaging in its next required full-scale
community-based or individual, facility-based
functional exercise following the onset of the
emergency event.

(ii) Conduct an additional annual exercise that
may include, but is not limited to the following:
(A) Asecond full-scale exercise that is
community-based or an individual, facility-based
functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop that is led by
a facilitator and includes a group discussion,
using a narrated, clinically-relevant emergency
scenario, and a set of problem statements,
directed messages, or prepared questions
designed to challenge an emergency plan.

(iii) Analyze the ICF/IID's response to and
maintain documentation of all drills, tabletop
exercises, and emergency events, and revise the
ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises
to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is
community-based; or

(A) When a community-based exercise is not
accessible, conduct an annual individual,
facility-based functional exercise every 2 years;
or.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

Facility ID: 922099

If continuation sheet Page 7 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2024

(B) If the HHA experiences an actual natural
or man-made emergency that requires activation
of the emergency plan, the HHA is exempt from
engaging in its next required full-scale
community-based or individual, facility based
functional exercise following the onset of the
emergency event.

(ii) Conduct an additional exercise every 2 years,
opposite the year the full-scale or functional
exercise under paragraph (d)(2)(i) of this section
is conducted, that may include, but is not
limited to the following:

(A) A second full-scale exercise that is
community-based or an individual, facility-based
functional exercise; or

(B) Amock disaster drill; or

(C) A tabletop exercise or workshop that is
led by a facilitator and includes a group
discussion, using a narrated, clinically-relevant
emergency scenario, and a set of problem
statements, directed messages, or prepared
questions designed to challenge an emergency
plan.

(iii) Analyze the HHA's response to and maintain
documentation of all drills, tabletop exercises, and
emergency events, and revise the HHA's
emergency plan, as needed.

*[For OPOs at §486.360]

(d)(2) Testing. The OPO must conduct exercises
to test the emergency plan. The OPO must do the
following:

(i) Conduct a paper-based, tabletop exercise or
workshop at least annually. A tabletop exercise is
led by a facilitator and includes a group
discussion, using a narrated, clinically relevant
emergency scenario, and a set of problem
statements, directed messages, or prepared

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 039] Continued From page 7 E 039

Facility ID: 922099

If continuation sheet Page 8 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

07/31/2024
STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE
WILKESBORO, NC 28697

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 039] Continued From page 8 E 039

questions designed to challenge an emergency
plan. If the OPO experiences an actual natural or
man-made emergency that requires activation of
the emergency plan, the OPO is exempt from
engaging in its next required testing exercise
following the onset of the emergency event.

(ii) Analyze the OPO's response to and maintain
documentation of all tabletop exercises, and
emergency events, and revise the [RNHCI's and
OPO's] emergency plan, as needed.

*[ RNCHIs at §403.748]:

(d)(2) Testing. The RNHCI must conduct
exercises to test the emergency plan. The RNHCI
must do the following:

(i) Conduct a paper-based, tabletop exercise at
least annually. A tabletop exercise is a group
discussion led by a facilitator, using a narrated,
clinically-relevant emergency scenario, and a set
of problem statements, directed messages, or
prepared questions designed to challenge an
emergency plan.

(ii) Analyze the RNHCI's response to and
maintain documentation of all tabletop exercises,
and emergency events, and revise the RNHCI's
emergency plan, as needed.

This STANDARD is not met as evidenced by:
Based on record review and interview, the facility
failed to conduct biennial testing of the facility's
emergency preparedness plan (EPP). The finding
Is:

Review on 7/30/24-7/31/24 of the facility's EPP
revealed no evidence of a full-scale
community-based or facility-based functional
exercise training to evaluate the emergency plan.

Interview on 7/31/24 with the qualified intellectual

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

disabilities professional (QIDP) confirmed that

Facility ID: 922099 If continuation sheet Page 9 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2024

CFR(s): 483.460(k)(1)

The system for drug administration must assure
that all drugs are administered in compliance with
the physician's orders.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to ensure all
medications were administered in compliance
with the physician orders for 1 of 6 clients (#2).
The finding is:

Observation in the group home on 7/31/24 at 6:38
AM revealed staff A to prompt client #2 to the
medication room. Continued observations
revealed staff A to prompt client #2 to sanitize her
hands. Further observation revealed staff A to
obtain the basket of medications from the
cabinet, educate client #2 and pour the client a
cup of water. Subsequent observations revealed
client #2 to choose applesauce and for staff A to
punch all 6:30 AM and 8:00 AM medications into
a medicine cup containing the applesauce. The
client was observed to be fed all medications
whole in applesauce and to drink water.

Review of records for client #5 on 7/31/24
revealed physician orders dated 7/31/24. Review
of the 7/31/24 physician orders revealed
medications to administer at 8:00 AM to be
Divalproex tab 500MG DR, Levetiraceta tab
750MG, Phenytoin EX cap 100MG, Propranolol
tab 10MG, and Vitamin D3 1000IU tab. Client
#2's Levothyroxine tab 88 MCG to be

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 039] Continued From page 9 E 039
the facility has no evidence of conducting a
full-scale community or facility-based training to
evaluate the emergency plan.
W 368 | DRUG ADMINISTRATION W 368

Facility ID: 922099

If continuation sheet Page 10 of 13.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(x4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE

WILKESBORO, NC 28697
ID

PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2024

(8)
COMPLETION
DATE

W 368 | Continued From page 10

administered at 6:30 AM was administered as
prescribed.

Interview with staff A on 7/31/24 revealed that the
staff confirmed with the surveyor that a
medication error occurred. Continued interview
with the staff revealed that client #2 was not
supposed to receive the 8:00 AM medications
and that nursing will be notified of the medication
error.

Interview with the facility nurse on 7/31/24
confirmed the 7/31/24 physician orders for client
#2 to be current. Continued interview with the
facility nurse revealed that staff should administer
all medications as prescribed.

MEAL SERVICES

CFR(s): 483.480(b)(2)(iv)

W 475

Food must be served with appropriate utensils.
This STANDARD is not met as evidenced by:
Based on observations, record reviews, and
interviews, the facility failed to assure 2 of 6
clients (#2 and #6) were provided appropriate
utensils to allow each client to eat as
independently as possible. The findings are:

Afternoon observations in the group home on
7/30/24 at 5:25 PM revealed all clients at the
dining room table preparing for the dinner meal.
The dinner meal consisted of the following: rice,
beef Lo mein stir fry, broccoli, and 2% milk.
Continued observations revealed client #2 and #6
to be provided a spoon only as they participated
in the dinner meal. Subsequent observations
revealed all clients to consume the dinner meal
with utensils provided. At no point during the
observation period were client #2 and #6 offered

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

W 368

W 475

Facility ID: 922099

If continuation sheet Page 11 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2024

a full place setting consisting of a fork, knife, and
spoon during the dinner meal.

Morning observations in the group home on
7/31/24 at 7:54 AM revealed all clients at the
dining room table preparing for the breakfast
meal. The breakfast meal consisted of the
following: cheese toast, strawberries, cereal with
milk, orange juice, and coffee. Continued
observations revealed client #2 to be provided
with a maroon spoon and client #6 to be provided
a regular spoon. Subsequent observations
revealed all clients consumed the breakfast meal
with the utensils provided. At no point during the
observation period were client #2 and #6 offered
a full place setting consisting of a fork, knife, and
spoon during the breakfast meal.

Review of records on 7/31/24 for client #2
revealed a person-centered plan (PCP) dated
1/24/24. Continued review of the PCP revealed
that the client has no adaptive equipment needs.
Continued review of the PCP revealed an
Occupational Therapy (OT) evaluation dated
9/22/23 to note that client #2 uses the following
utensil: spoon, fork, and knife.

Subsequent review of records on 7/31/24 for
client #6 revealed a PCP dated 12/5/23.
Continued review of the PCP revealed that the
client is on a regular diet and thin liquids with no
restriction or adaptive equipment used. Continued
review of the PCP revealed an OT evaluation
dated 9/22/23 to note that client #6 uses the
following utensils: fork, knife, and spoon.

Interview on 7/31/24 with the qualified intellectual
disabilities professional (QIDP) confirmed that the
PCP's for clients #2 and #6 were current.

Continued interview with the QIDP confirmed that

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 475 | Continued From page 11 W 475

Facility ID: 922099

If continuation sheet Page 12 of 13

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 08/01/2024
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

07/31/2024
STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE
WILKESBORO, NC 28697

client #2 and #6 should be provided with a full
placement of utensils which includes a fork, knife,
and spoon.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTJH11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 475 | Continued From page 12 W 475

Facility ID: 922099 If continuation sheet Page 13 of 13


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

PRINTED: 08/14/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION
COMPLETED

A. BUILDING
B. WING 08/09/2023
STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE

WILKESBORO, NC 28697

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(x8)
COMPLETION
DATE

W 474. MEAL SERVICES
CFR(s): 483.480(b)(2)(iii)

Food must be served in a form consistent with the
developmental level of the client.

This STANDARD is not met as evidenced by:
Based on observations, record review, and
interviews, the facility failed to serve food in a

orm consistent with the developmental levels and
prescribed diets of 4 of 5 clients (#1, #2, #3, and
#4). The findings are:

A. The facility failed to ensure the prescribed diet
or client #1. For example:

Observations in the group home on 8/8/23 at 5:30
PM revealed the dinner meal to be beef stew,
rice, biscuits with butter and chopped assorted
ruits. Continued observations revealed staff to
serve two whole biscuits to client #1, and client #1
fo consume both biscuits without staff cutting up
or modifying the biscuits in any manner.

Record review on 8/9/23 revealed a nutritional
evaluation for client #1 dated 4/10/23 stating that
he client is currently on a regular diet and
requires food to be cut to 1/2" consistency.

B. The facility failed to ensure the prescribed diet
or client #2. For example:

Observations of the same dinner meal revealed
staff to serve a whole biscuit to client #2, and the
client to consume the biscuit without staff cutting
up or modifying the biscuit in any manner.
Additional observation revealed staff to place a
second whole biscuit in front of client #2, then
return and break up the biscuit before assisting
the client to eat the biscuit.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

Ww 474

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 30HJ11

Facility ID: 922099 If continuation sheet Page 1 of 3

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

PRINTED: 08/14/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING 08/09/2023
STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE

Record review on 8/9/23 revealed a nutritional
diet order change for client #2 dated 6/1/23
stating, "Client has been putting too much food in
his mouth at once and had a choking incident
5/16/23. Diet consistency changed to 1 inch with
ground meats." Additional record review revealed
an incident report dated 5/16/23 which indicated,
"While eating lunch got choked and | did the
Heimlich and was cleared. Will consult with
nutritionist to get diet consistency changed."

C. The facility failed to ensure the prescribed diet
or client #3. For example:

Observations of the same dinner meal revealed
staff to serve two whole biscuits to client #3, and
he client to consume both biscuits without staff
cutting up or modifying the biscuits in any
manner.

Record review on 8/9/23 revealed a nutritional
evaluation for client #3 dated 2/16/23 stating that
he client is currently on a 1500 calorie weight
loss diet and requires food to be cut to 1"
consistency.

D. The facility failed to ensure the prescribed diet
or client #4. For example:

Observations of the same dinner meal revealed
staff to serve two whole biscuits to client #4, and
he client to consume both biscuits without staff
cutting up or modifying the biscuits in any
manner.

Record review on 8/9/23 revealed a nutritional
evaluation for client #4 dated 11/22/22 stating that
he client is currently on a low sodium diet and
requires food to be cut to 1/2" consistency.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 30HJ11

LAKEWOOD
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 474 Continued From page 1 W 474

Facility ID: 922099 If continuation sheet Page 2 of 3

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G229

NAME OF PROVIDER OR SUPPLIER

PRINTED: 08/14/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING 08/09/2023
STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE

Interview with the Qualified Intellectual Disability
Professional (QIDP) and Director of Nursing
(DON) for the facility on 8/9/23 confirmed the diet
orders are current and each client should have
had their food served in a consistency
appropriate to their needs as set forth in their
respective nutritional orders.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 30HJ11

LAKEWOOD
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 474 Continued From page 2 W 474

Facility ID: 922099 If continuation sheet Page 3 of 3


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

PRINTED: 08/17/2022
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
34G229 B. WING 08/16/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
LAKEWOOD 554 RIDGE LANE
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000. INITIAL COMMENTS W 000
This facility is in compliance with the
CONDITIONS OF PARTICIPATION for
Intermediate Care Facilities for Individuals with
Intellectual Disabilities found at 42 CFR 483.400
THROUGH 483.460 AND 42 CFR 483.480
(General/Health Requirements).
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:OATV11

Facility ID: 922099 If continuation sheet Page 1 of 1


raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

PRINTED: 09/07/2021
FORM APPROVED
OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
346229 B. WING 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
LAKEWOOD 554 RIDGE LANE
WILKESBORO, NC 28697
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000. INITIAL COMMENTS W 000
Arevisit was conducted on 9/2/21 for all previous
deficiencies cited on 6/9/21. All deficiencies have
been corrected and no new noncompliance was
found. The facility is in compliance with all
regulations surveyed.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: 0QFX12 Facility ID: 922099 If continuation sheet Page 1 of 1


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

PRINTED: 06/18/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

06/09/2021
STREET ADDRESS, CITY, STATE, ZIP CODE

554 RIDGE LANE
WILKESBORO, NC 28697

(x4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

ID PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

COMPLETION
DATE

W 288

MGMT OF INAPPROPRIATE CLIENT

W 288

BEHAVIOR
CFR(s): 483.450(b)(3)

Techniques to manage inappropriate client
behavior must never be used as a substitute for
an active treatment program.

This STANDARD is not met as evidenced by:
Based on observations, record review and
interviews, the team failed to assure techniques
to manage inappropriate behavior were not used
as a substitute for active treatment for 6 of 6
clients (#1, #2, #3, #4, #5 and #6) relative to
television remote access. The finding is:

Observations during the 6/8-9/21 survey revealed
a television in the living room that various clients
at various times were observed to sit in the living
room and watch. Continued observation of the
living room area on 6/8-9/21 revealed no remote
control to the television.

Further observation on 6/9/21 at 8:10 AM
revealed staff B to remove a television remote
from the kitchen cabinet and to enter the living
room where client #4 was watching television.
Subsequent observation revealed staff B to
change the television channel and to engage
client #4 in a preferred channel selection.
Additional observation revealed staff B to return
the television remote to the kitchen cabinet after
assisting client #4 with identifying a preferred
channel.

Interview with staff A on 6/9/21 revealed the

television remote is kept in the kitchen cabinet
due to behaviors of some clients with breaking,
losing or hiding the remote control. Continued

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 0QFX11

Facility ID: 922099 If continuation sheet Page 1 of 5

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(x4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 06/18/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

06/09/2021

ID PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX
TAG
DEFICIENCY)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE

COMPLETION
DATE

W 288 | Continued From page 1

interview with staff A verified clients #1, #2 and #4
did not have personal televisions in their bedroom
and were dependent on the living room television
to have the ability to watch television. Interview
with the facility qualified intellectual disabilities
professional (QIDP) on 6/9/21 verified the remote
control to the group home living room television
should not be kept in the kitchen cabinet.

DRUG STORAGE AND RECORDKEEPING
CFR(s): 483.460(1)(2)

W 382

The facility must keep all drugs and biologicals
locked except when being prepared for
administration.

This STANDARD is not met as evidenced by:
Based on observations and interview, the facility
failed to keep a prescription topical locked for 1 of
3 sampled clients residing in the facility (#3). The

finding is:

Observation in the group home on 6/9/21 at 7:55
AM revealed staff A to enter the bedroom of client
#3 and to exit with the client's shower box that
was taken to a hallway bathroom. Continued
observation revealed staff A to leave client #3's
shower box unattended in the bathroom, with the
bathroom door open, and to return to client #3's
room. Observation of the contents of client #3's
shower box revealed a bottle of shampoo with a
prescription label. Subsequent observation
revealed the bathroom door to remain open and
client #3's shower box to sit unattended from 7:59
AM until 8:04 AM.

Review of records for client #3 on 6/9/21 revealed
physician orders dated 5/26/21. Continued

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0QFX11

W 288

W 382

Facility ID: 922099

If continuation sheet Page 2 of 5

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(x4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PRINTED: 06/18/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

06/09/2021

ID PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX
TAG
DEFICIENCY)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE

COMPLETION
DATE

W 382 | Continued From page 2

review of the current physician orders for client #3
revealed an order for Ketoconazole 2% shampoo
with the directive to apply to scalp, leave on 5
minutes before washing; 3 times weekly.

Interview with staff A on 6/9/21 verified client #3
has a prescribed shampoo that is kept in the
client's shower box. Continued interview with
staff A revealed staff are allowed to store
medicated shampoo in the client's shower box
because it is a shampoo and used during
showers. Interview with the facility nurse on
6/9/21 revealed client #3's prescribed shampoo
should not be kept in the clients shower box and
should not be left unattended. Continued
interview with the facility nurse verified a
prescription strength shampoo should be kept
locked in the medication room and the medication
record should be signed when staff administer the
shampoo.

SPACE AND EQUIPMENT

CFR(s): 483.470(g)(2)

W 436

The facility must furnish, maintain in good repair,
and teach clients to use and to make informed
choices about the use of dentures, eyeglasses,
hearing and other communications aids, braces,
and other devices identified by the
interdisciplinary team as needed by the client.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interview, the facility failed to provide teaching
relative to eyeglasses for 1 of 3 sampled clients
(#5). The finding is:

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0QFX11

W 382

W 436

Facility ID: 922099

If continuation sheet Page 3 of 5

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229

NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES

PRINTED: 06/18/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

06/09/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
554 RIDGE LANE
WILKESBORO, NC 28697

PROVIDER'S PLAN OF CORRECTION

ID (x8)

Observation in the group home throughout the
6/8-9/21 survey revealed client #5 to participate in
various activities to include: leisure activities at
the dining table, setting the table for the dinner
meal, meal participation, household chores and
medication administration. Continued
observations throughout the 6/8-9/21 survey
revealed client #5 to participate in activities
without the use of eyeglasses. Subsequent
observation revealed no prompts or direction
from staff for client #5 to wear eyeglasses.

Review of records for client #5 on 6/9/21 revealed
a person centered plan (PCP) dated 12/16/20
with training objectives relative to learning to use
a check register, make bed, privacy, brush teeth
and wash hands. Continued review of records for
client #5 revealed a behavior plan for target
behaviors of physical aggression, taking items
that belong to others, food snatching, verbal
aggression, false accusations, un-cooperation,
inappropriate touch, property destruction,
hyperactive behavior and depressed behavior.
Property destruction was defined as throwing
items, breaking items, hitting/kicking items or any
other attempt to destroy the environment.

Review of a vision consult for client #5 dated
5/7/19 revealed a diagnosis of myopia and
astigmatism. Further review of the current vision
consult revealed the recommendation to initiate
glasses to improve vision.

Interview with client #5 on 6/8/21 revealed she
had broke her eyeglasses and had new glasses
on order. Interview with facility staff verified client
#5 had broken her eyeglasses in her sleep and
new eyewear had been ordered. Continued
interview with facility staff verified client #5 has a

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0QFX11

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 436 | Continued From page 3 W 436

Facility ID: 922099 If continuation sheet Page 4 of 5

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

346229
NAME OF PROVIDER OR SUPPLIER

LAKEWOOD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

554 RIDGE LANE

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 06/18/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

06/09/2021

WILKESBORO, NC 28697

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 436 | Continued From page 4 W 436

history of breaking her eyeglasses as she will
throw them, sleep in them and is really rough with
care.

Interview with the facility qualified intellectual
disabilities professional (QIDP) verified client #5
has a history of breaking her eyeglasses due to
improper care. Continued interview with the
QIDP verified client #5 did not have a training
objective to address proper care of eyeglasses.
Subsequent interview with the QIDP revealed
client #5 could benefit from a program to address
proper care of her eyewear and it was unknown
why a program had not been implemented.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0QFX11

Facility ID: 922099

If continuation sheet Page 5 of 5