Deficiencies (last 7 years)
Deficiencies (over 7 years)
20.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
265% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
72% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate 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
Plan of Correction
Census: 107
Deficiencies: 1
Date: Feb 24, 2023
Visit Reason
The document is a plan of correction submitted by Wilshire at Lakewood Rehab Center addressing deficiencies related to abuse and neglect found during a survey.
Findings
The facility failed to protect two sampled residents from physical altercations involving other residents, resulting in injuries. The facility implemented corrective actions including staff training, monitoring, and interventions to prevent further incidents.
Deficiencies (1)
F 600: The facility failed to prevent verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion as evidenced by physical altercations between residents causing injuries. The deficiency was corrected on 2/13/23 with implementation of policies and interventions.
Report Facts
Facility census: 107
Inspection Report
Routine
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Census: 114
Deficiencies: 18
Date: Nov 7, 2022
Visit Reason
The inspection was the annual survey of Wilshire at Lakewood Rehab Center to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including resident rights related to resident/family group responses, accident hazard supervision, dietary staffing and food safety, and policies/procedures. Several deficiencies were cited with varying severity levels.
Deficiencies (18)
F565 Resident/Family Group and Response: The facility failed to respond to grievances made during resident council meetings, including dietary concerns and food quality issues.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to conduct a post-fall assessment and notify appropriate parties after a resident fall on 10/1/22.
F801 Qualified Dietary Staff: The facility failed to employ a dietary manager and ensure sufficient dietary staffing and oversight.
F802 Sufficient Dietary Support Personnel: The facility failed to provide sufficient dietary support personnel to safely carry out food and nutrition services.
F803 Menus Meet Resident Needs/Prep in Adv/Followed: The facility failed to post menus, follow their own menu, and follow recipes for pureed foods.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to ensure food was palatable, served at safe temperatures, and properly monitored food temperatures.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to keep kitchen walls and ice maker clean and maintain proper food storage and temperature logs.
F813 Personal Food Policy: The facility failed to ensure staff awareness of designated refrigerators for resident perishable items and proper labeling and storage.
A4013 Policies/Procedures-Operational: The facility failed to develop policies and procedures applicable to operation to ensure residents' health and safety.
A4074 Protective Oversight, Voluntary Leave: The facility failed to ensure 24-hour protective oversight and supervision for residents on voluntary leave.
A4075 Nursing Care per Res: The facility failed to provide personal attention and nursing care consistent with current acceptable nursing practice.
A4087 Dr Notification-Change in Condition: The facility failed to notify the resident's physician of significant changes in condition.
A4088 Notify Responsible Party-Change in Condition: The facility failed to notify the responsible party of significant changes in resident condition.
A4089 Inform Administrator of Accidents: The facility failed to inform the administrator of accidents, injuries, and unusual occurrences affecting residents.
A5005 Hot Food Hot, Cold Food Cold: The facility failed to assure hot food is served hot and cold food is served cold.
A5014 Personnel Sufficient, Trained: The facility failed to ensure sufficient and properly trained personnel for food preparation and service.
A5022 Standardized Recipes Used: The facility failed to use a file of standardized recipes for food preparation.
A7015 Food-Protected, Temp, Need to Contact DHSS: The facility failed to protect food from contamination and maintain required temperatures.
Report Facts
Facility census: 114
Inspection Report
Plan of Correction
Census: 110
Deficiencies: 2
Date: Jul 11, 2022
Visit Reason
The inspection was conducted to assess compliance with quality of care regulations following incidents involving resident injuries and falls.
Findings
The facility failed to obtain physician orders and notify the physician for two residents after falls, and documentation and treatment orders for wounds were incomplete or missing. Multiple resident injuries were not properly managed or documented according to regulatory standards.
Deficiencies (2)
F684 Quality of care: The facility failed to obtain physician orders and notify the physician for two residents after falls, and did not properly document or treat wounds and injuries.
A4075 Nursing care per resident condition: The facility did not provide personal attention and nursing care consistent with current acceptable nursing practice, as evidenced by the F684 deficiency.
Report Facts
Facility census: 110
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Harris | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 5
Date: May 24, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident's rights and an incident involving two residents in a sexual situation.
Complaint Details
The complaint investigation was substantiated. The incident involved two residents engaging in consensual sexual activity. The facility initially sent one resident to the hospital for examination without the resident's consent. Interviews with staff, residents, and the physician confirmed no abuse or injury occurred, and both residents were alert and able to consent.
Findings
The facility failed to ensure one sampled resident's rights were respected when the resident was sent to the hospital for examination without honoring their choice and wishes. The investigation found the sexual interaction between two residents was consensual and no abuse occurred.
Deficiencies (5)
F550 Resident Rights. The facility failed to ensure one resident's rights were adhered to when sending the resident to the hospital for examination against their choice and wishes.
A8013 Right to Plan Care/Refuse Treatment. The facility did not afford residents the opportunity to refuse treatment or participate in care planning as required.
A8032 Residents Communicate With Persons of Choice. The facility did not fully meet regulations allowing residents to communicate and associate freely.
A8033 Private Meeting Areas Available. The facility failed to provide private meeting areas assuring resident privacy.
A8042 Resident Lives Not Regulated/Controlled. The facility did not adequately regulate or control residents' personal lives beyond reasonable policies.
Report Facts
Facility census: 106
Inspection Report
Plan of Correction
Census: 108
Deficiencies: 1
Date: Apr 12, 2022
Visit Reason
The document is a Plan of Correction submitted by Wilshire at Lakewood Rehab Center following a deficiency related to failure to provide CPR to a resident requiring emergency care.
Findings
The facility failed to provide continuous cardiopulmonary resuscitation (CPR) to a resident who had a physician order for full code. Staff did not verify the resident's code status promptly, delaying CPR initiation despite the resident having no heartbeat or respirations.
Deficiencies (1)
F 678 Cardio-Pulmonary Resuscitation (CPR) requirement was not met as the facility failed to provide CPR to a resident requiring emergency care prior to EMS arrival. Staff did not verify the resident's code status and delayed CPR despite no heartbeat or breathing.
Report Facts
Facility census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Scott Harris | Administrator | Signed the Plan of Correction document |
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: 117
Deficiencies: 4
Date: Dec 29, 2021
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to assess compliance with COVID-19 testing and immunization requirements for residents and staff.
Findings
The facility failed to implement a system to accurately ensure required COVID-19 testing for staff and residents, and failed to provide education and documentation regarding COVID-19 vaccinations for residents who refused the vaccine. Several residents tested positive for COVID-19 and the facility did not maintain proper testing records.
Deficiencies (4)
F886: The facility failed to implement a system to ensure routine COVID-19 testing of all staff and residents per CMS guidelines, including documentation of testing and results.
F887: The facility failed to provide education and documentation regarding COVID-19 vaccinations for residents who refused the vaccine, and did not maintain proper vaccination records.
A4085: The facility failed to use acceptable infection control procedures to prevent the spread of infection and failed to report communicable diseases within seven days as required.
A8013: The facility failed to afford residents the opportunity to participate in planning their care and treatment, including refusal of treatment, with proper documentation.
Report Facts
Facility census: 117
Resident positive COVID-19 cases: 6
Staff positive COVID-19 cases: 6
Resident charts for audit: 15
Inspection Report
Routine
Deficiencies: 0
Date: Jun 8, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Feb 11, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related regulations and recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
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 |
Inspection Report
Plan of Correction
Census: 142
Deficiencies: 16
Date: Jan 31, 2020
Visit Reason
The document is a Plan of Correction submitted by Wilshire at Lakewood in response to deficiencies cited during a survey conducted on January 31, 2020.
Findings
The facility was found to have multiple deficiencies related to resident rights, quality of care, infection control, medication administration, and safety practices. The Plan of Correction outlines corrective actions to address these issues and prevent recurrence.
Deficiencies (16)
F550 Resident Rights: The facility failed to ensure staff treated residents with dignity and respect, including privacy and timely response to call lights.
F561 Self-Determination: The facility did not provide a policy regarding resident rights to make choices about significant aspects of their lives, including snacks and bedtime routines.
F578 Advance Directives: The facility failed to provide appropriate documentation and information regarding advance directives to residents.
F584 Safe/Clean/Comfortable Environment: The facility failed to maintain a clean and safe environment, including housekeeping and refrigeration policies.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide proper notice and documentation for resident transfers and discharges.
F637 Comprehensive Assessment After Significant Change: The facility failed to complete timely assessments and care plans after significant changes in resident status.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive care plans addressing residents' needs.
F658 Respiratory/Tracheostomy Care and Suctioning: The facility failed to provide adequate respiratory care and suctioning consistent with professional standards.
F669 Bedrails: The facility failed to ensure proper use and assessment of bedrails to prevent resident injury.
F690 Urinary Incontinence: The facility failed to provide appropriate care and assessment for residents with urinary incontinence.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to provide adequate care for residents with respiratory needs.
F700 Bedrails: The facility failed to assess and monitor residents for risks related to bedrails and side rails.
F761 Label/Store Drug and Biologicals: The facility failed to properly label and store medications and biologicals.
F800 Provided Diet Meets Needs of Each Resident: The facility failed to provide appropriate dietary services and monitor resident preferences.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to maintain sanitary food preparation and storage conditions.
F880 Infection Prevention & Control: The facility failed to implement effective infection control practices, including hand hygiene and cleaning protocols.
Report Facts
Facility census: 142
Plan of Correction completion date: 2020
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jan 31, 2020
Visit Reason
The document is a Plan of Correction related to a Life Safety Code inspection conducted at Wilshire at Lakewood on 01/31/2020.
Findings
The facility failed to ensure smoke walls in attic spaces were completely sealed to prevent smoke transfer, affecting all 10 smoke compartments. The facility was granted a waiver to complete repairs due to high costs and has partially completed the work with plans to finish by fall 2020.
Deficiencies (3)
K372: The facility failed to ensure smoke walls in attic spaces were completely sealed to prevent smoke transfer, affecting all 10 smoke compartments. Repairs were partially completed with a waiver granted to finish by fall 2020.
K003: The facility meets the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
A3001: The building is not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2).
Report Facts
Number of smoke compartments affected: 10
Date of survey: Jan 31, 2020
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 15
Date: Feb 11, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations and investigate complaints related to resident care and facility operations.
Findings
The facility was found deficient in multiple areas including resident rights, grievances, investigation of alleged violations, transfer and discharge procedures, care planning, medication management, infection control, and environmental safety. Several residents were found to have unmet care needs and the facility failed to consistently follow policies and procedures.
Deficiencies (15)
F550 Resident Rights: The facility failed to ensure residents were treated with dignity and respect, maintain privacy, and provide appropriate perineal care.
F585 Grievances: The facility failed to resolve grievances timely and did not maintain confidentiality or proper documentation.
F610 Investigation/Prevent/Correct Alleged Violation: The facility failed to thoroughly investigate and report alleged abuse and injuries.
F622 Transfer and Discharge Requirements: The facility failed to document and communicate resident transfer and discharge information properly.
F656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive care plans addressing residents' needs.
F658 Services Provided Meet Professional Standards: The facility failed to provide care and services consistent with professional standards.
F689 Free from Accident Hazards/Supervision/Devices: The facility failed to prevent falls and provide adequate supervision and interventions.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to provide proper care for residents with catheters and prevent urinary tract infections.
F732 Posted Nurse Staffing Information: The facility failed to post accurate nurse staffing information as required.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to ensure appropriate use and monitoring of psychotropic medications.
F759 Free from Medication Error Rts 5 Prcnt or More: The facility failed to maintain medication error rates below 5 percent.
F760 Free from Significant Medication Errors: The facility failed to prevent significant medication errors related to insulin administration.
F809 Frequency of Meals/Snacks at Bedtime: The facility failed to provide adequate snacks and meals to residents.
F880 Infection Prevention & Control: The facility failed to maintain an effective infection prevention and control program.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain a safe and sanitary environment, including issues with furnace room and black substance on walls.
Report Facts
Facility census: 136
Medication error rate: 14.8
Medication error rate: 5
Inspection Report
Life Safety
Census: 136
Capacity: 170
Deficiencies: 12
Date: Feb 11, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations at Wilshire at Lakewood.
Findings
The facility failed to meet several life safety code requirements including building construction standards, egress door functionality, fire alarm system maintenance, cooking facility protections, electrical system testing, and proper storage of oxygen and gas equipment. Deficiencies affected multiple smoke compartments and potentially all residents.
Deficiencies (12)
K161 Building Construction Type and Height: The facility failed to maintain construction standards required by NFPA 101, including gaps and damage in walls and ceilings affecting smoke compartments.
K222 Egress Doors: Doors in required means of egress were locked with padlocks, preventing rapid removal of occupants and violating NFPA 101 requirements.
K324 Cooking Facilities: The facility failed to ensure cooking equipment was protected by fire suppression systems and prohibited cooking in resident rooms, risking resident safety.
K345 Fire Alarm System Testing and Maintenance: The facility did not maintain complete documentation of fire alarm inspections and testing as required by NFPA 72.
K353 Sprinkler System Maintenance and Testing: The facility failed to ensure timely inspection and testing of the sprinkler system, risking fire protection for residents.
K363 Corridor Doors: The facility failed to maintain the 20-minute fire rating on corridor doors due to holes, gaps, and improper latching, compromising smoke containment.
K372 Subdivision of Building Spaces - Smoke Barrier: The smoke barrier walls had gaps and holes that were not properly repaired, affecting all smoke compartments.
K521 HVAC: The facility failed to provide documentation demonstrating smoke damper testing and maintenance, potentially affecting smoke control systems.
K781 Portable Space Heaters: A portable space heater was found in an unauthorized location and was immediately removed to prevent fire hazards.
K914 Electrical Systems - Maintenance and Testing: The facility failed to assess and document electrical receptacles at resident locations, risking electrical hazards.
K920 Electrical Equipment - Power Cords and Extension Cords: Unsafe use of power strips and extension cords was observed in multiple resident care areas, risking fire hazards.
K923 Gas Equipment - Cylinder and Container Storage: Unsecured oxygen tanks were found in resident rooms and therapy areas, posing safety risks.
Report Facts
Facility capacity: 170
Census: 136
Inspection Report
Annual Inspection
Census: 146
Deficiencies: 12
Date: Apr 5, 2018
Visit Reason
Annual inspection survey conducted on 04/05/2018 to assess compliance with federal and state regulations at Wilshire at Lakewood nursing facility.
Findings
The facility was found to have multiple deficiencies including failure to provide timely meal service, incomplete accounting of residents' personal funds, inadequate comprehensive care plans, improper medication labeling and storage, insufficient infection control practices, and failure to provide proper assistance with activities of daily living. The facility census was 146 during the survey.
Deficiencies (12)
F550 Resident Rights: Facility failed to ensure residents in the main dining room were served in a timely manner to eat with their table mates.
F568 Accounting and Records of Personal Funds: Facility failed to provide each resident a full and complete accounting of their Resident Trust Fund account quarterly.
F656 Develop/Implement Comprehensive Care Plan: Facility failed to have complete and comprehensive care plans for sampled residents including pressure ulcer goals and interventions.
F658 Services Provided Meet Professional Standards: Facility failed to ensure staff provided care and treatment in accordance with professional standards, including flushing PICC lines and feeding tube placement.
F677 ADL Care Provided for Dependent Residents: Facility failed to assure staff provided proper perineal care to incontinent residents.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to ensure safe transfers and proper use of mechanical lifts for residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to provide proper catheter care and handwashing to prevent urinary tract infections.
F761 Label/Store Drugs and Biologicals: Facility failed to label and store medications properly, including expired medications and open multi-dose bottles.
F809 Frequency of Meals/Snacks at Bedtime: Facility failed to provide timely and adequate snacks to residents at bedtime.
F812 Food Procurement, Store, Prepare, Serve, Sanitary: Facility failed to maintain sanitary conditions in food storage and preparation areas.
F880 Infection Prevention & Control: Facility failed to establish and maintain an effective infection prevention and control program including hand hygiene and catheter care.
F921 Safe/Functional/Sanitary/Comfortable Environment: Facility failed to provide backflow prevention devices on hand held showers and maintain sanitary conditions.
Report Facts
Facility census: 146
Residents affected: 36
Residents sampled: 29
Residents affected: 5
Residents affected: 4
Residents affected: 3
Residents affected: 29
Inspection Report
Life Safety
Census: 146
Capacity: 170
Deficiencies: 8
Date: Apr 5, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility was found deficient in multiple areas related to fire safety, including lack of placards near K-type fire extinguishers, inadequate maintenance and testing of sprinkler systems, failure to maintain fire-rated corridor doors, insufficient staff training on evacuation and fire drills, unsafe use of power strips, and improper storage and handling of oxygen cylinders.
Deficiencies (8)
K324 Cooking Facilities: The facility lacked a placard near the K-type fire extinguisher in the kitchen directing staff to activate the fire suppression system before use.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure sprinkler heads were free of dirt, dust, lint, and corrosion and did not have required five-year internal pipe inspections or gauge calibrations.
K363 Corridor - Doors: The facility failed to maintain the 20-minute fire rating of corridor doors by using non-rated foam to fill gaps between doors and frames in six of ten smoke compartments.
K711 Evacuation and Relocation Plan: Staff were not adequately informed or trained on evacuation procedures, fire drills, or use of fire extinguishing devices, affecting emergency readiness.
K712 Fire Drills: The facility failed to conduct fire drills at varied times on all shifts as required, potentially affecting resident safety during emergencies.
K920 Electrical Equipment - Power Cords and Extension Cords: Power strips were used improperly in patient care areas, creating tripping hazards and fire risks in six of ten smoke compartments.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to properly store oxygen cylinders and maintain clear signage in the storage room, risking safety violations.
K926 Gas Equipment - Qualifications and Training: Staff were not adequately trained on the handling and maintenance of medical gases and oxygen equipment, risking improper use.
Report Facts
Facility capacity: 170
Resident census: 146
Smoke compartments affected: 6
Smoke compartments affected: 6
Fire drills conducted: 3
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