Lakewood Health System

Inspection findings

1. Feb 19, 2026 Health · 3 findings
   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Mar 6, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Mar 6, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Mar 2, 2026 · CMS fire safety

2. Dec 4, 2024 Fire Safety · 3 findings
   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Dec 12, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0753 Miscellaneous Deficiencies

     Have restrictions on the use of highly flammable decorations.

     Corrected Dec 12, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Dec 12, 2024 · CMS fire safety

3. Jul 30, 2024 MDH complaint investigation · 1 finding
   • Severity not stated

     H54205429C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

4. Jul 17, 2024 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jul 5, 2024 · CMS health inspection

5. Jun 10, 2024 MDH complaint investigation · 1 finding
   • Severity not stated

     H54203935C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

6. May 17, 2024 MDH complaint investigation · 1 finding
   • Severity not stated

     H54203104C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

7. Nov 8, 2023 Health · 7 findings
   • Not serious Scope/severity E

     F0576 Resident Rights Deficiencies

     Ensure residents have reasonable access to and privacy in their use of communication methods.

     Corrected Nov 20, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0585 Resident Rights Deficiencies

     Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

     Corrected Nov 20, 2023 · CMS health inspection

   • Not serious Scope/severity C Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Nov 20, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0623 Resident Rights Deficiencies

     Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

     Corrected Nov 20, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Nov 20, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Nov 20, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Nov 20, 2023 · CMS fire safety

8. Oct 11, 2023 MDH complaint investigation · 1 finding
   • Severity not stated

     H13295701C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

9. Aug 29, 2023 MDH complaint investigation · 1 finding
   • Severity not stated

     H54204410C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

10. Aug 11, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Sep 9, 2023 · CMS health inspection

11. Feb 2, 2022 MDH complaint investigation · 1 finding
    • Severity not stated

      H5420068C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

12. Dec 14, 2021 MDH complaint investigation · 1 finding
    • Severity not stated

      H5420063C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

13. May 24, 2021 MDH complaint investigation · 2 findings
    • Severity not stated

      H5420055C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H5420057C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

14. Feb 21, 2020 MDH complaint investigation · 1 finding
    • Severity not stated

      H5420043C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• ALBRECHT, CHRISTINE — operational/managerial control, NOT APPLICABLE, since 06/01/2020
• ANDERSON, BRAD — operational/managerial control, NOT APPLICABLE, since 08/13/2014
• BAUMAN, ALICIA — operational/managerial control, NOT APPLICABLE, since 10/09/2022
• BJERGA, JUDITH — corporate director, NOT APPLICABLE, since 01/01/2007
• BJERGA, LISA — operational/managerial control, NOT APPLICABLE, since 03/07/2016
• BJERGA, LISA — corporate officer, NOT APPLICABLE, since 03/07/2016
• BRICHACEK, AMY — corporate director, NOT APPLICABLE, since 01/01/2021
• CICHOS, JEF — corporate director, NOT APPLICABLE, since 07/01/2016
• DANIELS, MELISSA — w-2 managing employee, NOT APPLICABLE, since 09/15/2016
• DOBSON, KATHLEEN — operational/managerial control, NOT APPLICABLE, since 12/01/2014
• GROVE, SARA — corporate director, NOT APPLICABLE, since 04/24/2014
• HAEHNEL, BILLY — corporate director, NOT APPLICABLE, since 11/01/2015
• HANSEN, LANA — corporate director, NOT APPLICABLE, since 01/01/2008
• HOEMBERG, BEVERLY — corporate director, NOT APPLICABLE, since 01/01/2011
• JORDAHL, STEPHANIE — corporate director, NOT APPLICABLE, since 07/01/2021
• KRAUSE, NORMAN — corporate director, NOT APPLICABLE, since 07/01/2018
• KRAY, RYAN — corporate director, NOT APPLICABLE, since 10/01/2021
• LEVEILLE, LINDSAY — corporate director, NOT APPLICABLE, since 07/01/2023
• LINDOW, MELISSA — operational/managerial control, NOT APPLICABLE, since 08/27/2023
• MCILRAVY, CURTIS — corporate officer, NOT APPLICABLE, since 07/01/2014
• MUELLER, ROBERT — corporate director, NOT APPLICABLE, since 06/25/2015
• NEISESS, CORRINE — operational/managerial control, NOT APPLICABLE, since 09/01/2018
• NELSON, KEVIN — corporate director, NOT APPLICABLE, since 04/01/2018
• NEWTON RICE, LYNN — operational/managerial control, NOT APPLICABLE, since 06/30/1980
• PEET, SUSAN — corporate director, NOT APPLICABLE, since 01/01/2021
• POTTRATZ, ELIZABETH — corporate director, NOT APPLICABLE, since 01/01/2023
• REYCRAFT, JOSEPH — corporate officer, NOT APPLICABLE, since 08/28/2022
• REYCRAFT, JOSEPH — operational/managerial control, NOT APPLICABLE, since 08/28/2022
• ROEDER, JAMES — operational/managerial control, NOT APPLICABLE, since 10/15/2017
• SCHOECK, KAITLYN — corporate director, NOT APPLICABLE, since 08/07/2017
• STORBAKKEN, RONALD — corporate director, NOT APPLICABLE, since 01/01/2000
• SWENSON, WADE — corporate director, NOT APPLICABLE, since 01/01/2023
• THEURER, MARY — corporate officer, NOT APPLICABLE, since 01/01/2010
• WICHT, EMIL — corporate director, NOT APPLICABLE, since 01/01/1973
• WOLHOWE, CRAIG — corporate officer, NOT APPLICABLE, since 06/11/1997
• WOLHOWE, CRAIG — operational/managerial control, NOT APPLICABLE, since 06/11/1997