Lakewood A Continuing Care Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on review of the facility Reportable Incident Form, record review and interviews, the facility failed to notify timely the Medical Provider of an unwitnessed fall with head injury for 1 of 3 residents reviewed who sustained a head injury from a fall (Resident #1 [Resident R1]).On 11/18/25, the facility's Reportable Incident Form that was sent to Licensing and Certification, dated 11/10/25, was reviewed. Documentation on the form indicated that on 11/7/25 at approximately 11:00 p.m., Resident R1 had an unwitnessed fall in his/her room. From the fall, Resident R1 sustained an injury to the left forehead, a black eye on the right periorbital, a skin tear to the right upper lip and a skin tear to the left wrist.A review of the clinical record indicated that on 11/7/25 the Charge Nurse/Registered Nurse (RN1) who assessed Resident R1 after the fall filled out a Risk Management Form. RN1 documented a message containing information regarding the fall on the Risk Management Form for the Medical Provider to review at his/her next visit. The Provider reviewed the message and visited Resident R1 on 11/10/25.On 11/18/25 at 11:26 a.m., in an interview with the surveyor, RN1 confirmed that he did not immediately notify the Medical Provider or Third Eye Health agency of the fall with head injury.On 11/18/25 at 11:50 a.m., in an interview with the surveyor, the Director of Nursing confirmed that the Medical Provider and/or the health agency Third Eye were not notified immediately of the unwitnessed fall with head injury.

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.

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

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lakewood A Continuing Care Center

220 Kennedy Memorial Dr Waterville, ME 04901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on the Reportable Incident Form, the facility policy and procedure for reporting and interviews, the facility failed to notify the State Agency (Division of Licensing and Certification) of an unwitnessed fall with head injury for 1 of 3 residents reviewed that sustained a head injury from a fall.On 11/18/25, the facility's Reportable Incident Form that was sent to Licensing and Certification, dated 11/10/25, was reviewed.

Documentation on the form indicated that on 11/7/25 at approximately 11:00 p.m., Resident R1 had an unwitnessed fall in his/her room. From the fall, Resident R1 sustained an injury to the left forehead, a black eye on the right periorbital, a skin tear to the right upper lip and a skin tear to the left wrist.A review of the facility's reporting

a fall with injury policy and procedure indicated under Section: To state and federal agencies: Falls with serious injury must be reported to the stated survey agency within 24 hours.On 11/18/25 at 11:26 a.m., in

an interview with the surveyor, RN1 confirmed that he did not notify the Division of Licensing and Certification of the fall with head injury.On 11/18/25 at 11:50 a.m., in an interview with the surveyor, the Director of Nursing confirmed that Licensing and Certification was not notified of the unwitnessed fall with head injury in a timely manner.

Event ID:

Facility ID:

If continuation sheet