Lakewood Care Center: Abuse Reporting Failures - ME
The unwitnessed fall occurred at Lakewood A Continuing Care Center on November 7 around 11:00 p.m. The resident sustained an injury to the left forehead, a black eye on the right side, a skin tear to the right upper lip and a skin tear to the left wrist, according to the facility's incident report reviewed by federal inspectors.
The charge nurse who assessed the resident after the fall documented the injuries on a risk management form but only left a message for the medical provider to review "at his/her next visit." The doctor didn't see that message or examine the resident until November 10 — three days after the fall.
Federal regulations require nursing homes to immediately notify residents' doctors and family members of situations that affect the resident, including injuries from falls. Head injuries are considered particularly serious because they can indicate traumatic brain injury or internal bleeding that may not be immediately apparent.
When questioned by inspectors on November 18, the charge nurse confirmed they did not immediately notify the medical provider or Third Eye Health agency about the fall with head injury. The Director of Nursing also confirmed that neither the medical provider nor the health agency were notified immediately of the incident.
The facility was required to report the incident to state licensing authorities, which it did on November 10 — the same day the doctor finally examined the resident. The three-day gap between the fall and medical evaluation could have delayed critical treatment if the resident had developed complications from the head injury.
Falls are a leading cause of injury and death among nursing home residents. The Centers for Disease Control and Prevention reports that each year, about 1,800 nursing home residents die from fall-related injuries. Head injuries from falls can be particularly dangerous for elderly residents, who may be taking blood-thinning medications or have conditions that increase their risk of serious complications.
The inspection was conducted as part of a complaint investigation at the 220 Kennedy Memorial Drive facility. Lakewood A Continuing Care Center has not yet submitted its plan of correction for the violation, which federal inspectors classified as causing minimal harm or potential for actual harm to residents.
Third Eye Health, mentioned in the inspection report as an agency that should have been notified, appears to be a healthcare monitoring service used by the facility. The inspection report did not specify whether the resident's family was notified of the fall.
The violation highlights a communication breakdown in the facility's emergency response procedures. While the charge nurse properly assessed and documented the resident's injuries, the decision to wait for the doctor's next scheduled visit rather than making immediate contact potentially put the resident at risk.
Nursing homes are required to have 24-hour nursing coverage and protocols for handling medical emergencies. When residents suffer head injuries, immediate medical evaluation is critical to rule out concussion, internal bleeding, or other serious complications that may not be immediately visible.
The resident's current condition was not disclosed in the inspection report, which focused on the facility's failure to follow proper notification procedures rather than the medical outcome of the incident.
Federal inspectors reviewed three residents who had sustained head injuries from falls during their investigation, but found notification failures in only this one case. The facility must now develop and implement corrective measures to ensure immediate notification of medical providers when residents suffer injuries, particularly head trauma from falls.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakewood A Continuing Care Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
Lakewood A Continuing Care Center in WATERVILLE, ME was cited for abuse-related violations during a health inspection on November 18, 2025.
The unwitnessed fall occurred at Lakewood A Continuing Care Center on November 7 around 11:00 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.