Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
67% occupied
Based on a October 2024 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 1
Date: Oct 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the development and completion of Individual Service Plans (ISP) for residents in the assisted living facility.
Findings
The facility failed to complete Individual Service Plans for five residents upon admission. Staff interviews and record reviews confirmed incomplete documentation of ISPs, which are required to be completed within five days of admission and updated every six months.
Deficiencies (1)
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop. The facility failed to complete Individual Service Plans for five residents upon admission as required by regulation.
Report Facts
Facility census: 45
Residents without completed ISP: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Level One Medication Aide (L1MA) B | Interviewed regarding ISP updates and resident information | |
| Level One Medication Aide (L1MA) C | Interviewed regarding ISP availability for staff | |
| Licensed Practical Nurse (LPN) A | Interviewed about nursing duties and ISP updates | |
| Administrator | Interviewed about ISP completion responsibilities and program manager status |
Inspection Report
Plan of Correction
Census: 46
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
The inspection was conducted to investigate and document deficiencies related to resident dignity and privacy at Lakewood-Assisted Living by Americar, following an incident involving a Certified Medication Aide and a resident's refusal to take medication.
Findings
The facility failed to ensure all residents were treated with dignity and respect, as evidenced by a verbal altercation between staff and a resident during medication administration. The resident exhibited memory lapse and mood issues, and staff did not follow proper procedures to manage the resident's refusal of medication, leading to a confrontation.
Deficiencies (1)
19 CSR 30-88.010(29) Dignity/Privacy: The facility failed to treat all residents with dignity and respect, as a Certified Medication Aide became involved in a verbal altercation with a resident who declined medication. Staff did not follow policy to avoid taking medication from the resident's hand and failed to communicate properly during the incident.
Report Facts
Facility census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA A | Certified Medication Aide | Involved in verbal altercation with resident during medication administration |
| CMA D | Certified Medication Aide | Provided statements regarding incident and resident behavior |
| Program Director | Interviewed regarding incident and staff communication | |
| Administrator | Administrator | Reviewed incident and provided written statement |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Mar 23, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations of abuse involving a staff member physically removing and restraining a resident and failure to report the abuse in a timely manner.
Complaint Details
The complaint investigation substantiated that a staff member (LIMA A) physically restrained Resident #1 and failed to report the incident to management and the state agency promptly. The violation was classified as imminent danger Class I. The facility had taken corrective action by terminating the staff member and removing the imminent danger at the time of exit.
Findings
The facility was found to have failed to protect residents from abuse by a staff member who physically restrained a resident and failed to report the incident promptly. The violation was determined to be at an imminent danger Class I level, but the imminent danger was removed at the time of exit.
Deficiencies (1)
19 CSR 30-88.010(22) Free From Abuse: The facility failed to protect residents from abuse when a staff member physically removed and restrained a resident and failed to report the abuse to management and the state agency in a timely manner.
Report Facts
Facility census: 40
Compliance date: Apr 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LIMA A | Level One Medication Aide | Named in abuse finding for physically restraining a resident and failing to report the incident |
| Program Manager E | Conducted investigation and assessments related to the abuse incident | |
| LIMA B | Staff member involved in the incident and interviewed during investigation |
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 1
Date: Nov 8, 2022
Visit Reason
The inspection was conducted to assess compliance with medication destruction and record-keeping regulations at Lakewood Assisted Living by Americar.
Findings
The facility failed to maintain accurate records of destroyed narcotic medications, with discrepancies found in narcotic counts for four residents. The Administrator acknowledged mismanagement of narcotics and incomplete documentation of medication destruction.
Deficiencies (1)
19 CSR 30-86.047(56)(E)(1-2) Medications-Return to RX / Destroy, Records. Facility staff failed to maintain accurate records of destroyed narcotic medications when significant doses were missing and one narcotic did not match the count sheet for four residents.
Report Facts
Facility census: 44
Completion date for plan of correction: Dec 10, 2022
Compliance date for ongoing compliance: Dec 12, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alicia Robin | Administrator | Named in interview regarding narcotic medication mismanagement and signed plan of correction |
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 2
Date: Apr 11, 2022
Visit Reason
The document is a plan of correction related to deficiencies found during a facility inspection on April 11, 2022.
Findings
The facility failed to ensure delayed egress locks and smoke doors met regulatory requirements, affecting all 47 residents. Observations showed missing required signage and doors that did not close or latch properly.
Deficiencies (2)
19 CSR 30-86.022(7)(E) Locked Exit Doors: The facility failed to ensure delayed egress locks were installed according to NFPA 101 standards. Observations showed doors requiring a code to exit and missing required signage.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: The facility failed to ensure doors in smoke partitions were self-closing and properly latched. Observations showed a smoke door did not close or latch on six attempts.
Report Facts
Facility census: 47
Residents affected: 47
Deficiency count: 2
Inspection Report
Plan of Correction
Census: 49
Deficiencies: 1
Date: Mar 12, 2020
Visit Reason
The inspection was conducted to assess compliance with tuberculosis (TB) screening requirements for residents and staff at Lakewood-Assisted Living by Americare.
Findings
The facility failed to ensure required two-step TB screening tests were completed timely for three staff members. The Director of Nursing acknowledged responsibility for administering the tests and noted delays in completion for some staff.
Deficiencies (1)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure the required two-step tuberculosis screening tests were completed for three staff members. Documentation showed delays and incomplete testing within the required timeframes.
Report Facts
Facility census: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LIMA B | Staff member with delayed TB testing documented | |
| PCA C | Staff member with delayed TB testing documented | |
| Director of Nursing | Director of Nursing | Interviewed regarding TB testing responsibilities and delays |
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 1
Date: Mar 27, 2019
Visit Reason
The inspection was conducted as a fire safety inspection focusing on the sprinkler system maintenance and testing compliance.
Findings
The facility failed to maintain their sprinkler system according to the National Fire Protection Association (NFPA) 25, 1998 edition. The annual inspection showed dry pendant heads over ten years old without evidence of required testing.
Deficiencies (1)
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing. The facility failed to maintain their sprinkler system as required, with dry pendant heads over ten years old lacking documented testing or inspection since 2011.
Report Facts
Facility census: 47
Inspection Report
Life Safety
Census: 25
Deficiencies: 5
Date: Jul 11, 2018
Visit Reason
The inspection was a fire safety inspection conducted to assess compliance with hazardous area requirements, emergency lighting, flame resistance of curtains and drapes, wastebasket requirements, and electrical wiring maintenance.
Findings
The facility failed to maintain self-closing doors to hazardous areas, emergency lighting, flame-resistant curtains and drapes, proper wastebaskets, and electrical wiring in good repair. Multiple deficiencies were identified that potentially affect all 25 residents.
Deficiencies (5)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility failed to install and maintain self-closing devices on doors leading to hazardous areas. The self-closing device on the A hall mechanical room door was broken and not operational.
19 CSR 30-86.022(12)(C) Emergency Lighting - Battery Powered, 1.5 hrs: The facility failed to test and maintain emergency lighting. Emergency lights in the television room, D hall, and above the resident kitchen exit failed to activate during testing.
19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant: The facility failed to show documentation of fire resistance for curtains and drapes in multiple resident rooms and exit doors.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility used non-fire-resistant wastebaskets in the kitchen, marketing office, laundry room, and resident rooms, contrary to regulations requiring metal or UL/FM fire-resistant rated wastebaskets.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to maintain the electrical system in good repair. Multiple Ground Fault Circuit Interrupter (GFCI) duplex outlets were not functioning properly.
Report Facts
Facility census: 25
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