University Health Lakewood Medical Center

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the resident's responsible party when the resident was observed to have bruising and swelling near his/her right eye for one sampled resident (Resident #3) out of three residents sampled residents. The facility census was 134 residents. Review of the facility's policy titled Disclosure of Adverse Events to Patients and Families dated as revised 10/8/25 showed when an adverse event occurred, family members or resident representatives were entitled to a prompt explanation of what occurred and what action may be required as a result of the event. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure six sampled residents (Residents #2, #5, #10, #11, #13, #14) out of 14 sampled residents were treated with dignity and respect and cared for in a manner that promoted maintenance or enhancement of their quality of life. The facility census was 130 residents. The Administrator and Director of Nurses (DON) was notified on 3/20/26 of Past Non-Compliance which occurred on 3/12/26. On 3/12/26 the facility administration suspended Certified Nurses Aide (CNA) A, begun an investigation, and notified appropriate parties. Facility staff and residents were interviewed. Facility staff in-services were started on abuse and neglect policy which included dignity for all employees. The deficiency was corrected on 3/13/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate storage and labeling of medications throughout the facility's medication carts and medication cabinets which had the potential to affect all residents within the facility. The facility census was 131 residents. Review of the facility's policy titled Medication Purchasing and Storage dated 1/10/24 showed:-Medications would be stored consistently with manufacturers' recommendations and in a manner that reduces the opportunity for a medication error to occur.-When medications were placed into active stock, expiration dates would be reviewed and stock rotated so products with the earliest expiration dates were dispensed first.1. Observation on 8/20/25 at 11:34 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #31) was invited to their care plan meeting out of 26 sampled residents. The facility census was 131 residents. A facility policy related to care plan invitations was requested and not received prior to exit.1. Review of Resident #31's admission record showed he/she admitted to the facility with a diagnosis of Hemiplegia (paralysis to one side of the body) and Hemiparesis (partial weakness affecting one side of the body) following Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain) affecting the left non-dominant side. Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) note dated 6/12/25 at 4:51 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered with an error rate of less than five percent (%). Two medication errors were detected out of 38 observed opportunities resulting in a medication rate of 5.26 %. One error involved administration of insulin (medication used to treat high blood sugars) with an insulin pen (an injection device that delivers preloaded insulin by dialing a desired dose) and one error involved the correct method for measuring the quantity of a liquid medication). In addition, the facility failed to have a policy that addressed insulin pens, including to follow manufacturers' instructions regarding how many units of insulin to use in priming differed insulin pens. The facility census was 131 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Residents #1 and #2) out of 10 sampled residents were free physical and mental abuse from Certified Nurse Aide (CNA) A. On 4/17/25, Certified Nurse Aide (CNA) A grabbed Resident #1's arm, resulting in bruising and calling the resident a name. Additionally, CNA A refused to take the resident to the toilet and told the resident to be quiet. Later the same day, Resident #2 was heard asking CNA A to let the water warm up before being showered. CNA A said he/she didn't have time and placed the resident into the shower and sprayed him/her with cold water and then left him/her alone in the shower room partially naked for approximately five minutes while the resident was heard repeatedly yelling loudly for help and that he/she was cold while in the shower room and heard crying following the shower. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely reporting of abuse allegations per the facility policy for two sampled residents (Resident #1 and #2) out of 10 sampled residents. Certified Nurse Aide (CNA) A was allowed to continue his/her shift on 4/17/25 and to work part of his/her shift on 4/18/25 potentially affecting all residents in his/her assignment. The facility census was 134 residents. On 4/30/25 the Administrator was notified of the past noncompliance which took place from mid-afternoon on 4/17/25 and 4/18/25. Corrective measures began immediately. The CNA was suspended. All staff were re-educated on abuse and neglect reporting. The deficiency was corrected on 4/18/25. Review of the facility's Abuse and Neglect policy, revised 7/26/24, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure discharge/transfer documentation was completed to include reasons for the discharge/transfer, discharge plan and notification of the resident's responsible party, for one sampled resident (Resident #1), who was discharged to another facility, out of five sampled residents. The facility census was 147 residents. Review of the Facility's Transfer and Discharges/Notice of Proposed Discharge Policy revised on 6/27/24 showed: -Transfer and discharge will be handled appropriately to ensure proper notification and assistance to resident and families in accordance with federal and state specific regulations. -Procedure: --The transfer or discharge is necessary for the resident welfare and the resident needs cannot be met in their current placement in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an emergency discharge letter was provided to the resident's and/or the resident's representatives with Durable [NAME] of Attorney (DPOA) (a person who has the legal authority and responsibility to make decisions for another person) including the right to appeal the discharge and Ombudsman (a person who investigates, reports on, and helps settle complaints) contact information upon discharge for one sampled resident (Resident #1) out of 5 sampled residents. The facility census of 147 residents. Review of the Facility's Transfer and Discharges/Notice of Proposed Discharge Policy revised on 6/27/24 showed: -Transfer and discharge will be handled appropriately to ensure proper notification and assistance to resident and families in accordance with federal and state specific regulations. -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were followed to prevent contamination and spread of infection for one sampled resident (Resident #4) who was on contact droplet isolation for Respiratory Syncytial Virus (RSV - a respiratory virus that infects the lungs and breathing passages and can be serious, especially for infants and older adults) out of two sampled residents who were on isolation on the third floor south unit. The sample was five residents. The facility census was 145 residents. Review of the facility's Isolation Precautions policy and procedure, dated 2/20/23, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide residents and/or the resident's responsible party's timely notifications (verbal and/or in writing) prior to a roommate change for three sampled residents (Residents #1, #2, and #3) out of five sampled residents. The facility census was 149 residents. Review of the facility's Resident Right's policy dated 11/16 showed: -Notification of changes: --A facility must immediately inform the resident, consult with the resident's physician; and notify, consistent with his/her authority, the resident representative(s) when there is a change in room or roommate assignment. Review of the facility's current Census List dated 2/27/24 showed Resident #1 and Resident #2 were currently roommates. 1. Review of Resident #1's Face Sheet showed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's discharge notification contained the correct contact information for appeal rights for one sampled resident (Resident #1) out of 5 sampled residents. The facility census was 149 residents. On 2/27/24, the Administrator was notified of the past noncompliance which occurred on 10/31/23. The facility administration was notified during the resident's appeal process that the discharge notification contact information was incorrect. Inservices were provided to staff who were involved in preparing the discharge notification notices on 11/2/23. Discharge notices sampled after 11/2/23 contained the correct contact information for the appeal process. The deficiency was corrected on 11/2/23. Review of the facility policy Transfers and Discharges/Notice of Proposed discharge date d 3/5/19 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure intravenous (IV) services were provided consistently with professional standards of practice by failing to obtain physician orders to monitor and maintain a peripheral intravenous catheter (a thin, flexible tube placed into a vein using a needle to allow for the administration medications, fluids and/or blood products)and to individualize a comprehensive care plan for IV therapy on one sampled resident (Resident #71) out of 32 sampled residents. The facility census was 163 residents. Review of the facility policy and procedure for Intravenous Therapy Peripheral in Long Term Care reviewed 8/2/23 showed: -Assess IV site for erythema (redness), warmth, edema (collection of fluid causing swelling), and drainage. Document per routine ongoing assessment and as needed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's orders for two sampled resident's (Resident #37 and #112) who received Continuous Positive Airway Pressure (CPAP- a machine that uses mild air pressure delivered by mask to keep breathing airways open during sleep )to ensure cleansing, sanitary storage and maintenance of the resident's CPAP nasal mask, machine and supplies, to assess and document the use of the resident's CPAP, ensure the resident's Minimum Data Set (MDS- a federally mandated assessment completed by the facility for care planning) included CPAP use and care plans addressed the use of CPAP, out of 32 sampled residents. The facility census was 163 residents. A policy and procedure was requested from the facility and was not provided prior to exit. 1. Review of Resident #37's Face Sheet showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there were physician orders for hemodialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood), for monitoring the resident's fistula (a surgically created connection between a vein and artery that allows access to the bloodstream for dialysis) and for monitoring the resident after dialysis for one sampled resident (Resident #43). Additionally the facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding care and services for two sampled residents (Residents #43 and #121) out of 32 sampled residents. The facility census was 163 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (medications which affect psychic function, behavior, or experience) were administered for targeted behaviors, to monitor and document the targeted behaviors, and monitor for adverse reaction for medications for two sampled residents (Resident #87 and #112) out of 32 sampled residents. The facility census was 93 residents. Review of facility policy entitled Psychotropic Medication used in Long Term Care with an approval date of 7/20/18 showed: -Residents that received psychotropic medication would have appropriate evaluation, documentation and monitoring as defined by state and federal regulations. -Residents who have not used psychotropic medications were not given them unless it is necessary to treat a specific condition as diagnosed and documented in the clinical record. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow facility policies and procedures for checking the nurse aide registry on all newly hired employees in accordance with federal requirements prior to employing four of nine employees sampled for the background screening process. The facility census was 171 residents. Record review of the facility's Abuse and Neglect policy and procedure dated 8/1/17, showed the purpose was to ensure facility staff was doing all that is within their power to prevent occurrences of abuse, mistreatment, exploitation, involuntary seclusion, injuries of unknown origin and misappropriation of property for all patients. It showed: -The facility will screen potential employees for a history of abuse, neglect, or mistreating patients, including checking with the appropriate licensing boards and registries. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have coordination of care between hospice (end of life) and the facility and to ensure staff were instructed where and how to retrieve the hospice providers electronic documentation for five sampled residents (Residents #45, #85, #129, #118, and #166); to transcribe ongoing hospice physician orders for two sampled residents (Residents #45 and #85); and to obtain current physician orders for hospice services for one sampled resident (Resident #118) out of 36 sampled residents. The facility census was 171 residents. Record review of the facility undated policy titled Hospice showed: -There was no outlined procedure for facility staff and Hospice staff to share communication/documentation. -There was no mention of the requirement to obtain physician orders for Hospice or palliative care services. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to safely secure the medication storage cart on multiple occurrences for one out of eight medication carts; to safely secure facility stock of over the counter medication storage cabinet for one out three storage cabinets; to label and date a multi-use vial of medication when open, and failed to ensure the crash cart was locked for one out of two crash carts. The facility census was 171 residents. Record review of the facility's Medication Storage in LTC (Long Term Care) Policy, dated 10/12/2012, showed: -Medications and biologicals were stored safely, securely and properly. -Medication supply was accessible only by licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) assessments were accurate and included hospice services (end of life care) for three sampled residents (Resident #25, #109, and #670) out of 36 sampled residents. The facility census was 171 residents. Record review of the facility policy titled Minimum Data Set /Quarterly Assessment Form dated November 1, 2016 showed: -The results of the assessment are used to develop, review and revise the resident's comprehensive plan of care. -The MDS Coordinator must assure that all sections of the MDS have been completed. 1. Record review of Resident #25's Face Sheet showed he/she was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident and/or his/her family received a copy of the resident's baseline care plan for one sampled resident (Resident #670) out of 34 sampled residents. The facility census was 171 residents. 1. Record review of the resident's undated baseline care plan showed no documentation of the resident and/or his/her family receiving a copy. During an interview on 3/25/22 at 12:00 P.M., the Director of Nursing (DON) said: -Baseline care plans could be completed by the admitting nurse. -He/she did not know if there was any documentation of residents and/or their families receiving copies of the baseline care plans. -He/she assumed residents and/or their families received copies of the baseline care plans since they had meetings with the residents and their families when the residents were admitted to the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive care plan was completed to include interventions for behaviors for one sampled resident (Resident #78) who had a diagnosis of depression out of 36 sampled residents. The facility census was 171 residents. 1. Record review of Resident #78's Face Sheet showed he/she was admitted on [DATE], with diagnoses including high blood pressure, anemia (iron deficiency), shortness of breath, asthma (a respiratory condition where the airway is obstructed), and depression. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/17/22, showed the resident: -Had significant cognitive impairment. -Did not have any mood or behavioral symptoms within the lookback period. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and document pressure sores (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) that re-opened for one sampled resident (Resident #4); to complete weekly skin and/or wound assessments for two sampled residents (Residents #22 and #4); to discontinue applying wound care treatments once the wounds healed for one sampled resident (Resident #4); to provide ongoing wound care assessment and documentation of the resident's pressure ulcers, to update the comprehensive care plan to reflect the current condition and treatment, and to ensure appropriate physician orders for one sampled resident (Resident #52) out of 36 sampled residents. The facility census was 171 residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician's order for self care of Foley Catheter (or indwelling catheter, is a tube with retaining balloon passed through the urethra into the bladder to drain urine), was obtained and to have documentation of the education provided and formal evaluation of the resident's ability to provide self-care for one sampled resident (Resident #158) who had a history of bladder infections; to ensure infection control and prevention practices were followed in managing indwelling catheters and the associated drainage system for two sampled residents (Resident #25 and #109) out of 36 sampled residents. The facility census was 171 residents. Record review of the facility Urinary Catheter care Policy and Procedure dated 12/1/2019 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Pharmacist's recommendations were obtained and documented, to ensure the physician responded to the pharmacist's recommendations and responded timely for one sampled resident (Resident #148) out of 36 sampled residents. The facility census was 171 residents. 1. [...]