Lakewood Care Center: Notification Failures - ME
The unwitnessed fall occurred on November 7 at approximately 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 filed with state regulators.
The charge nurse who assessed the resident after the fall filled out a risk management form with information about the injuries. Rather than immediately contacting the medical provider, the nurse documented a message for the doctor to review "at his/her next visit."
The medical provider 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 and declines in condition. Head injuries from falls represent serious medical events that can worsen rapidly without prompt evaluation.
When questioned by federal inspectors on November 18, the charge nurse confirmed he did not immediately notify the medical provider or Third Eye Health agency of the fall with head injury. The facility's Director of Nursing also confirmed that neither the medical provider nor the health agency received immediate notification.
The inspection was triggered by a complaint. Federal surveyors reviewed three residents who had sustained head injuries from falls and found the notification failure affected one of them.
Lakewood A Continuing Care Center operates on Kennedy Memorial Drive in Waterville. The facility filed its incident report with Maine's licensing and certification office on November 10, the same day the medical provider finally examined the injured resident.
The delay meant the resident went three days without medical evaluation after sustaining multiple facial injuries and head trauma. During that time, potential complications from the head injury could have developed undetected.
Unwitnessed falls pose particular risks for nursing home residents, who often have conditions that increase their vulnerability to serious injury. When residents fall alone, staff must rely on physical examination and the resident's account to assess the extent of harm.
The charge nurse's decision to leave a message rather than make immediate contact violated the facility's obligation to ensure prompt medical attention for injured residents. The three-day gap between injury and evaluation represents exactly the kind of delay federal rules are designed to prevent.
Third Eye Health, mentioned in the inspection report as another entity that should have been notified, appears to be a healthcare service provider working with the facility. Like the medical provider, this agency received no immediate notification of the resident's condition.
The facility's risk management form system, while capturing information about the incident, failed to trigger the urgent communication required by federal standards. Documentation alone cannot substitute for direct, immediate contact with medical providers when residents suffer significant injuries.
Federal inspectors classified this as a violation causing minimal harm or potential for actual harm, affecting few residents. However, the failure to notify medical providers promptly after head injuries can lead to missed opportunities for intervention when complications develop.
The resident's injuries were substantial enough to require documentation in multiple locations — the risk management form, the incident report to state regulators, and the medical provider's notes from the delayed November 10 visit. The black eye, forehead injury, and facial cuts suggested significant impact from the fall.
Staff at nursing homes face numerous daily responsibilities, but immediate notification of medical providers after serious injuries remains a fundamental safety requirement. The three-day delay at Lakewood demonstrates how communication breakdowns can leave vulnerable residents without timely medical attention when they need it most.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Lakewood A Continuing Care Center in WATERVILLE, ME was cited for violations during a health inspection on November 18, 2025.
The unwitnessed fall occurred on November 7 at approximately 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.