Deficiencies (last 4 years)
Deficiencies (over 4 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
122 residents
Based on a November 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 1
Date: Nov 18, 2025
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to follow a resident's physician's order for no cardiopulmonary resuscitation (CPR) when the resident was found not breathing and without a heartbeat.
Complaint Details
Complaint 2619701. The facility was found non-compliant for not following Resident #147's DNR order during a cardiac arrest event. The Administrator was notified of past non-compliance, and the facility completed an internal investigation and staff in-service training. The resident's family was contacted and was not upset about the CPR efforts.
Findings
The facility failed to ensure that Resident #147's Do Not Resuscitate (DNR) order was followed, resulting in CPR being administered despite the order. EMS continued CPR despite being informed of the DNR status. The resident was found unresponsive and warm to touch, with signs indicating death prior to EMS arrival. The facility conducted staff training post-incident to verify code status before initiating CPR.
Deficiencies (1)
Failure to follow a resident's physician's order for no cardiopulmonary resuscitation (CPR) when the resident was found not breathing and without a heartbeat.
Report Facts
Resident census: 122
Sampled residents: 31
Duration of EMS CPR efforts: 25
Time EMS arrived after CPR started: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Charge nurse on the night shift who started CPR and called code | |
| Resident's physician | Provided opinion on CPR efforts and facility actions |
Inspection Report
Routine
Census: 123
Deficiencies: 2
Date: Nov 21, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in the nursing facility, specifically addressing medication administration and care related to residents' motion sickness and medication adherence.
Findings
The facility failed to adequately address motion sickness for Resident #37, including failure to administer prescribed anti-nausea medication prior to showers or bed baths, and failed to ensure Resident #92 took prescribed medications, as medications were left at bedside without proper administration.
Deficiencies (2)
Failure to address motion sickness and administer prescribed anti-nausea medication (Zofran) to Resident #37 prior to showers or bed baths.
Failure to ensure Resident #92 took prescribed medications; medications were left at bedside without physician order for self-administration.
Report Facts
Residents affected: 2
Sampled residents: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Reported resident's severe motion sickness and medication needs |
| CNA F | Certified Nursing Assistant | Provided showers and reported resident's requests for nausea medication |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding resident's motion sickness and medication administration policies |
| Primary Care Physician A | Primary Care Physician | Discussed medication orders and risks for Resident #37 |
| LPN E | Licensed Practical Nurse | Observed medications left at bedside and verified medication administration issues for Resident #92 |
| CMT A | Certified Medication Technician | Admitted to leaving medications at bedside for Resident #92 |
Inspection Report
Routine
Census: 123
Capacity: 170
Deficiencies: 11
Date: Nov 21, 2023
Visit Reason
Routine inspection of Wilshire at Lakewood Rehab Center to assess compliance with regulatory requirements including resident rights, PASARR screening, care planning, medication administration, bathing, foot care, medication storage, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to obtain written authorizations for resident funds, incomplete PASARR screenings, inadequate comprehensive care plans, failure to conduct timely care plan meetings, improper medication administration and storage practices, failure to provide scheduled bathing and foot care, improper handling of urinary catheters, and lapses in infection prevention and control practices.
Deficiencies (11)
Facility failed to obtain written authorizations from residents or their representatives to manage resident funds for 6 sampled residents.
Facility failed to provide required PASARR screening for two sampled residents.
Facility failed to develop and implement a comprehensive care plan addressing all resident needs for one sampled resident.
Facility failed to include and document participation of residents and/or representatives in care plan development for two sampled residents.
Facility failed to address motion sickness and ensure prescribed anti-nausea medication was given appropriately for one sampled resident; failed to ensure one resident took prescribed medications and medications were not left unattended.
Facility failed to provide scheduled bathing and showering for three sampled residents, resulting in poor hygiene.
Facility failed to provide appropriate foot care or podiatry referral for one sampled resident with diabetes.
Facility failed to ensure narcotic medication counts were accurate, properly documented, and signed by two nurses at shift changes for three sampled residents; failed to remove expired medications.
Facility failed to ensure urinary catheter tubing was kept off the floor during transfers for one sampled resident; failed to properly screen and document tuberculosis testing for two sampled residents.
Facility failed to maintain clean and sanitary food preparation areas, keep trash dumpsters properly closed, follow hair hygiene practices, and store food at proper temperatures.
Facility failed to ensure medication carts were locked when unattended, keys were secured, cleaning supplies and foreign objects were not stored with medications, opened medications were dated, and lacked a policy for opening automated medication machines during power outages.
Report Facts
Residents with accounts in Resident Trust Fund: 44
Residents sampled for PASARR screening: 25
Residents sampled for care planning: 25
Residents sampled for medication administration: 25
Residents sampled for bathing: 25
Residents sampled for urinary catheters: 4
Residents sampled for tuberculosis screening: 5
Expired Albuterol Sulfate packages: 11
Narcotic medication cards counted: 14
Lacosamide bottle volume discrepancy: 27
Morphine bottle volume discrepancy: 3.5
Oxycodone bottle volume discrepancy: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Provided Resident Trust Fund policy and forms; interviewed regarding unsigned authorization forms |
| Administrator | Administrator | Interviewed regarding PASARR screening and care plan meetings |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan development and care plan meetings |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan development, medication administration, bathing, catheter care, narcotic counts, and infection control |
| Licensed Practical Nurse E | Licensed Practical Nurse (LPN) | Interviewed and observed regarding medication administration, catheter care, and bathing |
| Certified Nursing Assistant A | Certified Nursing Assistant (CNA) | Interviewed regarding care plan meetings and bathing |
| Certified Nursing Assistant B | Certified Nursing Assistant (CNA) | Interviewed regarding care plan meetings and bathing |
| Certified Nursing Assistant D | Certified Nursing Assistant (CNA) | Observed and interviewed regarding catheter care and bathing |
| Certified Nursing Assistant E | Certified Nursing Assistant (CNA) | Interviewed regarding resident motion sickness and medication administration |
| Certified Nursing Assistant F | Certified Nursing Assistant (CNA) | Interviewed regarding resident motion sickness and medication administration |
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) | Interviewed regarding medication cart security and narcotic counts |
| Licensed Practical Nurse C | Licensed Practical Nurse (LPN) | Interviewed regarding expired medications and narcotic counts |
| Licensed Practical Nurse D | Licensed Practical Nurse (LPN) | Interviewed regarding narcotic counts |
| Licensed Practical Nurse H | Licensed Practical Nurse (LPN) | Interviewed regarding bathing schedule and resident refusals |
| Registered Nurse A | Registered Nurse (RN) | Interviewed regarding tuberculosis screening and narcotic counts |
| Pharmacist | Pharmacist | Interviewed regarding medication counts and pharmacy procedures |
| Pharmacy Director | Pharmacy Director | Interviewed regarding medication counts and pharmacy procedures |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding narcotic counts, medication cart audits, and medication discrepancies |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding narcotic counts and medication administration |
| Medical Director | Medical Director | Interviewed regarding narcotic counts and medication discrepancies |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and kitchen sanitation |
| Director of Maintenance | Director of Maintenance (DOM) | Interviewed regarding dumpster lids and facility inspections |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 1
Date: Feb 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a physical altercation between two residents (Resident #2 and Resident #3) at the facility.
Complaint Details
The complaint involved a physical altercation between Resident #2 and Resident #3 on 2/11/23. The facility investigated, notified the Administrator, Director of Nursing, State, physicians, and family members. Resident #3 was sent to the hospital twice for evaluation and medication management. Resident #2 had scratches and was placed on 1:1 observation. Staff were educated on abuse policies. Resident #3 exhibited aggressive and inappropriate behaviors post-incident and was awaiting placement at a Geriatric Psychiatric facility.
Findings
The facility failed to protect two sampled residents from a physical altercation involving hitting and scratching. The incident was investigated, staff were educated, and interventions were implemented including separating the residents and notifying appropriate parties. Resident #3 was sent to the hospital twice and placed on 1:1 observation. Resident #2 sustained scratches and was monitored. The facility followed its abuse policy and notified the state and physician.
Deficiencies (1)
Failed to protect residents from physical abuse during a resident-to-resident altercation.
Report Facts
Residents present: 107
Date of incident: Feb 11, 2023
Date of correction: Feb 13, 2023
Date of survey: Feb 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Registered Nurse | Witnessed and responded to the altercation, performed assessments, and directed staff to separate residents |
Inspection Report
Routine
Census: 92
Capacity: 170
Deficiencies: 10
Date: Mar 22, 2022
Visit Reason
Routine inspection of Wilshire at Lakewood Rehab Center to assess compliance with regulatory requirements including resident fund security, abuse reporting, care practices, and facility safety.
Findings
The facility failed to maintain adequate surety bond coverage for resident trust funds, timely report and investigate abuse allegations, provide proper care including nail care and wound treatment, ensure fall investigations and interventions, maintain food safety standards, and follow physician orders for catheter care and medication management.
Deficiencies (10)
Failed to produce a surety bond at an amount that sufficiently assured the security of all personal funds of residents deposited with the facility in the Resident Trust Fund.
Failed to timely report an allegation of abuse to the State Agency and failed to fully investigate the allegation and remove alleged perpetrators during the investigation.
Failed to provide nail care to a resident totally dependent on staff, resulting in long, thick fingernails that impaired use of telephone.
Failed to address ordered rectal wound treatment and document wound assessment for a resident with a rectal wound.
Failed to complete fall investigations and put individualized interventions in place for residents who sustained fractures from falls.
Failed to provide physician's orders for Foley catheter care, failed to follow orders, and improperly placed catheter bag during resident transfer.
Failed to notify physician and dietician of significant weight loss and ensure interventions were offered and implemented for residents with weight loss.
Failed to ensure a licensed nurse performed ongoing assessment and monitoring of dialysis site and communication with dialysis center, and failed to address resident's non-compliance with dialysis site assessment.
Failed to maintain kitchen and food storage areas clean, retain thermometers in refrigerators, safeguard against foreign material contamination, properly document food temperatures, and maintain cutting boards and utensils in good condition.
Failed to act on pharmacist's drug regimen review recommendations for a resident receiving psychotropic medications.
Report Facts
Residents affected: 64
Facility census: 92
Licensed capacity: 170
RTF accounts: 64
RTF balance: 83736.46
Weight loss percentage: 6.47
Weight loss percentage: 23
Missed medication administrations: 22
Missed wound treatments: 7
Missed catheter care: 10
Missed catheter care: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Interviewed regarding Resident Trust Fund bond coverage |
| Administrator | Administrator | Interviewed regarding Resident Trust Fund bond coverage and abuse reporting |
| Social Services Director | Social Services Director | Interviewed regarding abuse grievance and resident concerns |
| Certified Nursing Assistant B | Certified Nursing Assistant | Interviewed regarding abuse reporting and resident care |
| Certified Nursing Assistant E | Certified Nursing Assistant | Interviewed regarding abuse reporting and resident care |
| Registered Nurse A | Registered Nurse | Interviewed regarding abuse reporting and falls investigations |
| Corporate Nurse Consultant B | Corporate Nurse Consultant | Interviewed regarding abuse reporting and falls investigations |
| Certified Nursing Assistant F | Certified Nursing Assistant | Interviewed regarding abuse grievance |
| Certified Nursing Assistant G | Certified Nursing Assistant | Interviewed regarding abuse grievance |
| Social Services Designee | Social Services Designee | Received abuse grievance from resident |
| Agency Licensed Practical Nurse C | Agency Licensed Practical Nurse | Interviewed regarding catheter care and dialysis site assessment |
| Assistant Director of Nursing A | Assistant Director of Nursing | Interviewed regarding abuse reporting, falls, catheter care, dialysis site assessment, and drug regimen review |
| Assistant Director of Nursing B | Assistant Director of Nursing | Interviewed regarding nail care and catheter care |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding catheter care and drug regimen review |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding weight loss and catheter care |
| Certified Medication Technician A | Certified Medication Technician | Interviewed regarding supplement administration |
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding supplement administration |
| Rehabilitation Director/Physical Therapist Assistant A | Rehabilitation Director/Physical Therapist Assistant | Interviewed regarding resident therapy and fall prevention |
| Interim Dietary Manager | Interim Dietary Manager | Interviewed regarding kitchen and food safety |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including abuse reporting, falls, catheter care, dialysis, weight loss, and drug regimen review |
Inspection Report
Routine
Census: 142
Deficiencies: 19
Date: Jan 31, 2020
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and privacy, timely response to call lights, honoring resident preferences, care planning, medication administration, infection control, safe resident transfers, and food service. Specific issues included failure to maintain resident privacy, delayed call light responses, incomplete care plans, improper medication handling, inadequate catheter and perineal care, unsafe transfer techniques, and failure to maintain a clean and safe environment.
Deficiencies (19)
Failure to maintain resident dignity and privacy, including failure to knock before entering rooms and failure to maintain coverings on residents.
Failure to honor resident preferences for shower days, bedtime snacks, and wake times.
Failure to obtain appropriate documentation for advance directives and DNR orders.
Failure to monitor and defrost personal refrigerators as needed.
Failure to provide timely written notice of transfer or discharge to residents and their representatives.
Failure to complete a Significant Change in Status Minimum Data Set (MDS) for a resident admitted to hospice services.
Failure to develop and implement comprehensive, person-centered care plans addressing all resident needs, including pressure ulcers, hospice services, and use of side rails.
Failure to follow professional standards for medication administration, including dating insulin pens and discarding expired medications.
Failure to provide proper eye drop and nasal spray administration according to policy and physician orders.
Failure to provide complete perineal care and appropriate catheter care to prevent infections.
Failure to use proper techniques during resident transfers, including use of mechanical lifts and gait belts.
Failure to honor resident meal preferences and provide variety in food choices.
Failure to maintain kitchen and food service areas in a clean and sanitary condition, including sanitizer levels and cleaning schedules.
Failure to clean and maintain oxygen concentrator filters properly.
Failure to complete assessment, obtain consent, and document use of side rails for a resident.
Failure to ensure staff washed hands and changed gloves appropriately during perineal care and catheter care.
Failure to clean and disinfect resident mattresses and wheelchair cushions after soiling.
Failure to provide a clean field for blood glucose monitoring supplies.
Failure to ensure residents do not use their own cups to scoop ice from ice chests.
Report Facts
Facility census: 142
Deficiencies cited: 19
Urine volume: 500
LALM setting: 450
LALM setting: 180
LALM setting: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT E | Certified Medication Technician | Named in finding related to failure to maintain resident privacy and dignity |
| DON | Director of Nursing | Named in multiple findings related to resident care, privacy, infection control, and medication administration |
| CMT D | Certified Medication Technician | Named in finding related to urine odor on resident mattress |
| CNA C | Certified Nurse Aide | Named in findings related to perineal care and catheter care |
| CNA H | Certified Nurse Aide | Named in findings related to perineal care and catheter care |
| CNA I | Certified Nurse Aide | Named in findings related to resident transfer and perineal care |
| RN A | Registered Nurse | Named in findings related to insulin pen administration and blood glucose monitoring |
| CMT B | Certified Medication Technician | Named in findings related to medication cart and resident transfer |
| CNA D | Certified Nurse Aide | Named in findings related to resident transfer |
| CNA J | Certified Nurse Aide | Named in findings related to perineal care |
| CMT A | Certified Medication Technician | Named in findings related to nasal spray administration |
| LPN A | Licensed Practical Nurse | Named in findings related to wound care and catheter care |
| CNA B | Certified Nurse Aide | Named in findings related to incontinent care and wheelchair cleaning |
| CNA E | Certified Nurse Aide | Named in findings related to incontinent care and wheelchair cleaning |
| CNA A | Certified Nurse Aide | Named in findings related to catheter care and resident transfer |
| CNA C | Certified Nurse Aide | Named in findings related to catheter care |
| CNA B | Certified Nurse Aide | Named in findings related to incontinent care |
| CNA E | Certified Nurse Aide | Named in findings related to incontinent care |
| CMT B | Certified Medication Technician | Named in findings related to resident transfer |
| CNA I | Certified Nurse Aide | Named in findings related to resident transfer |
| CNA A | Certified Nurse Aide | Named in findings related to resident transfer |
| CNA H | Certified Nurse Aide | Named in findings related to catheter care |
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