Wilshire at Lakewood Rehab Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain a comprehensive 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 observation, interview, and record review, the facility failed to meet professional standards for one sample resident (Resident #5) when staff taped the resident's ileostomy (a surgical procedure that creates an opening in the abdominal wall through which the last part of the small intestine, called the ileum, is brought to the surface of the body) bag shut instead of using a clip and for one sampled resident (Resident #70) when staff failed to correct an order entry error related to weighing the resident daily and documenting the daily weights out of 31 sampled residents. The facility census was 122 residents. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one sampled resident's (Resident #147) physician's order for no cardiopulmonary resuscitation (CPR - any medical intervention used to restore circulatory and/or respiratory function that has ceased) was followed when the resident was found not breathing and having no heart beat out of 31 sampled residents. The facility census was 122 residents.1. The Administrator was notified on [DATE] of past non-Compliance which occurred on [DATE]. The facility had completed an internal investigation and had in-serviced all staff on [DATE]. The past non-compliance was corrected on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff were adequately documenting supplement usage for one sampled resident (Resident #5) out of 31 sampled residents. The facility census was 122 residents. Review of the facility policy titled Nutrition/Hydration Management dated 10/24/22 showed:-A resident was assessed for nutrition/hydration status by nursing during the admission process.-A comprehensive care plan would be developed by the interdisciplinary team that addressed nutrition/hydration and an individualized nutrition/hydration management program based on individualized assessed needs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two sampled residents (Resident #17 and #149) who were fed by enteral (a form of nutrition that is delivered into the digestive system as a liquid) means received the appropriate treatment and services to prevent complications of enteral feeding by failing to assess the percutaneous endoscopic gastrostomy tube (PEG tube) a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) for placement out of 31 sampled and five supplemental residents. The facility census was 122. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate under five percent (%) for one supplemental resident (Resident #149) out of five supplemental residents. Two medication errors were detected out of 28 observed opportunities resulting in an error rate of 7.14 %. The facility census was 122 residents. Review of the facility's policy titled Feeding Tube-Administration of Medication dated 10/24/22 showed staff needed to verify that medication cups were clear of any remnants of crushed pills or liquid medication. 1. Review of Resident #149's admission Record showed the resident was admitted to the facility with a diagnosis of gastrostomy (G-tube: surgical procedure that creates an opening in the stomach through the abdominal wall). [...]

Inspectors wroteBased on observation and interview, the facility failed to properly contain waste and refuse in outdoor dumpsters, to prevent the harboring and/or feeding of pests. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility and/or ate food from the kitchen. This facility had a census of 122 residents with a licensed capacity of 170 residents at the time of the survey.1. Observation on 9/15/25 between 11:43 A.M. and 2:41 P.M. during the initial Life Safety Code (LSC) facility outer perimeter inspection showed the following:-The south lid of the south dumpster outside the Service Hall was flipped back completely open.-The facility itself had large, wooded areas on the north and west sides. Observation on 9/17/25 at 11:44 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the walk-in refrigerator, and walk-in freezer floors clean; to maintain sanitary food preparation equipment; to keep trash dumpsters lidded; to follow correct hair hygiene practices; and to store foodstuffs within acceptable temperature parameters, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 123 residents with a licensed capacity for 170 residents at the time of the survey. 1. Observation on 11/13/23 between 9:01 A.M. and 10:57 A.M. during the initial kitchen inspection showed the following: -There was a sticky substance on the manual can opener blade by the microwave and also on the one by the Dry Storage (DS) room. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain written authorizations from residents or their representatives to hold, manage, safeguard, and account for their funds for 6 sampled residents (Residents #17, #45, #51, #59, #65, and #87) out of 44 residents who had an account in the Resident Trust Fund (RTF) in accordance with standard accounting practices and principles, as required by Federal regulations and the State of Missouri statutes. This deficient practice had the potential to affect all residents who held an account in the facility's resident trust. The facility census was 123 residents with a licensed capacity for 170 residents at the time of the survey. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Activities of Daily Living (ADL), bathing/showering, for two sampled residents (Resident #107 and #64) and to provide bathing for for one sampled resident (Resident #37) out of 25 sampled residents by not providing scheduled baths or showers, causing poor hygiene. The facility census was 125 residents. Review of the facility's Showering a Resident policy, dated 10/24/22, showed: -A bath/shower was given to the residents to provide cleanliness, comfort and to prevent body odor. -Residents were offered a shower a minimum of once weekly and given per resident request. -Report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to the charge nurse. -Update the resident's care plan as needed. -Note: No procedure for documentation of bathing/showering and/or resident refusal was noted. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the narcotic count was correct by not ensuring two nurses were counting the narcotic medications at the beginning and end of each shift, and signing at the time the nurses counted the medications; to ensure nurses were not pre-signing the medication count sheet before counting with the second nurse; to ensure the two nurses verified the amount in the medication container was the same amount that was on the medication sheet for three sampled residents, (Resident #109, #19, and #114), and to ensure there were no expired medications out of 25 sampled residents. The facility census was 123 residents. Review of the facility's Medication Storage-Controlled Medication storage dated 11/'17 showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication carts were locked when staff was not in attendance of them, to ensure the keys to the medication cart which contained narcotics were not accessible to anyone walking by the medication cart, to ensure cleaning supplies were not in with the residents medications, to ensure other objects were not in with the residents medications, to ensure the residents prescribed medication had a date written on them after opening, and to have a policy of how to open the automated medication machine if the power went out. The facility census was 123 residents. Review of the facility's policy, Medication Storage, Controlled Medication Storage, dated 11/17 showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure urinary catheter (a tube passed through the urethra into the bladder to drain urine) tubing was kept off of the floor for one sampled resident (Resident #60) out of four residents sampled for urinary catheters and to properly screen and follow their policy for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for two sampled residents (Residents #10 and #218) out of five residents sampled for TB screening. This practice had the potential to affect all residents, employees and visitors to the facility. The facility census was 123 residents. Review of the facility's policy titled Tuberculosis - Screening dated as revised on 10/24/22 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Preadmission Screening and Resident Review [PASRR- a federally mandated preliminary assessment to determine whether a resident may have a mental illness (MI) or an intellectual disorder (ID), to determine the level of care needed. A level I was required for all residents and a level II if the resident tested positive for any MI or ID] for two sampled residents (Residents #29 and #40) out of 25 sampled residents. The facility census was 123 residents. Record review of the facility's PASRR policy dated October 24, 2022 showed: [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a Comprehensive Care Plan (a document describing agreed goals of care, and outlining planned medical, nursing and allied health activities for a patient) was developed and implemented for one sampled resident (Resident #29) out of 25 sampled residents. The facility census was 123 residents. Review of the facility's care plan policy dated October 24, 2022 showed: -The facility's Interdisciplinary Team (IDT) will develop a Comprehensive Care Plan for each resident. -The IDT may include the following individuals: --The attending Physician. --The Resident Assessment Coordinator. --The Director of Nursing (DON). -The Care Plan will include measurable objectives and time tables to meet a resident's medical, nursing, mental and psychosocial needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to include and document participation of the resident and/or the resident's representative(s) regarding care plan development for two sampled residents (Resident #70 and Resident #61) out of 25 sampled residents. The facility census was 123 residents. Review of the facility's Care Planning policy, dated 10/24/2022, showed: -The purpose of the policy was to ensure a comprehensive person-centered Care Plan was developed for each resident based on their individual assessed needs. -The Care Plan served as a course of action where the resident, resident's family and/or guardian or other legally authorized representative, resident's attending physician, and the Interdisciplinary Team (IDT) worked to help the resident move toward resident-specific goals that addressed the resident's medical, nursing, mental and psychosocial needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to address one sampled resident's motion sickness (Resident #37) and to ensure one sampled resident (Resident #92) took his/her prescribed medications out of 25 sampled residents. The facility census was 123 residents. Review of the facility's policy, Medication Administration, dated October 24, 2022 showed: -Medications may be administered one hour before or after the scheduled mediation administration time. -Medications would not be left at the bedside. 1. Review of Resident #37's progress notes dated September 2023, October 2023 and November 2023 showed no documentation regarding any nausea or vomiting. Review of the resident's comprehensive Certified Nursing Assistant's (CNA) shower review sheets dated September 2023 showed: -On 9/2/23, the resident received a bed bath. -On 9/30/23, the resident received a shower. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide toenail care or an appointment with a podiatrist for one sampled resident (Resident #60) out of 25 sampled residents who had a diagnosis of diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) which posed a risk to foot health. The census was 123 residents. Review of the facility's policy titled Grooming care of fingernails and toenails revised 10/24/22 showed: -Residents who had diabetes would not have their toenails trimmed by Certified Nursing Assistants (CNA). -High risk residents who had toenail issues such as thick toenails or toenails with a fungal infection would be referred to a podiatrist. 1. Review of Resident #60's medical record showed no podiatry progress notes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure urinary catheter (a tube passed through the urethra into the bladder to drain urine) tubing was in a safe place during a transfer for one sampled resident (Resident #60) out of four residents sampled for urinary catheters. The facility census was 123 residents. Review of the facility's catheter care policy dated as revised 10/24/22 showed instructions to ensure the catheter tubing was properly anchored to prevent urethral tear. 1. Review of Resident 60's care plan dated 9/22/23 showed the resident had a urinary catheter. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 10/4/23 showed the following staff assessment of the resident: -Cognitively intact. -Had an indwelling catheter. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete fall investigations and put individualized interventions in place for one sampled resident (Resident #20) who sustained a cervical fracture (a broken bone in the neck region of the spine) from a fall on 1/22/22; and to complete fall investigations and put individualized interventions in place for one sampled resident (Resident # 87) who sustained a left first (big) toe fracture (broken) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility's Falls- Clinical Protocol policy, revised March 2018 showed: -The physician will help identify residents with a history of falls and risk factors for falling. -Staff will ask the resident and the caregiver or family about a history of falling. [...]

Inspectors wroteBased on interview and record review, the facility 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 (RTF). This deficient practice had the potential to affect 64 residents who held an account in the facility's resident trust. The facility census was 92 residents with a licensed capacity for 170 residents. 1. Record review of the Missouri Department of Health and Senior Services (DHSS) Active Bonds list dated 3/3/22 and printed prior to this survey, showed this facility's RTF bond amount coverage on file at their central office was $45,000.00. During an interview on 3/16/22 at 12:33 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the kitchen, dry storage, and walk-in refrigerator and walk-in freezer floors clean; to retain thermometers in all refrigerators to confirm adequate temperature ranges; to safeguard against foreign material possibly getting into food and/or beverages; to properly document food temperatures to ensure they were thoroughly cooked to lessen the chance of bacterial contamination; and to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 92 residents with a licensed capacity for 170. 1. Observations during the Kitchen inspections on 3/14/22 at 8:57 A.M. and at 10:47 A.M. showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the State Agency (SA) immediately, but no later than two hours after the allegation of abuse was made and to inform the State of the results of the facility's Abuse Investigation within five days for one sampled resident (Resident #34) out of 20 sampled residents or to show in their Abuse Investigation why reporting an allegation of abuse was not necessary. The facility census was 92 residents. Record review of the facility's Abuse Investigation and Reporting policy, revised July, 2017 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to fully investigate an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) and to follow the facility policy and procedure to ensure the alleged perpetrators (AP) were removed from the facility during the time of the abuse investigation for one sampled resident (Resident #34) out of 20 sampled residents. The facility census was 92 residents. Record review of the resident's Abuse Prevention Program, revised December 2016 showed: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. -As part of resident abuse prevention the Administrator will: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure written notice was given to the resident/resident's representative prior to transfer to the hospital for one sampled resident (Resident #20) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility Transfer or Discharge Notice policy, revised December 2016 included: -The facility would provide a resident and/or the resident's representative with a thirty (30) day written notice of an impending transfer or discharge. -Under the following circumstance, the notice would be given as soon as it was practicable (able to be done or put into practice successfully) but before the resident's transfer or discharge: An immediate transfer or discharge was required by the resident's urgent medical needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the written bed hold policy notice was given to the resident/resident's representative prior to transfer to the hospital for one sampled resident (Resident #20) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility Transfer or Discharge Notice policy, revised December 2016 included: -The facility would provide a resident and/or the resident's representative with a thirty (30) day written notice of an impending transfer or discharge. -Under the following circumstance, the notice would be given as soon as it was practicable (able to be done or put into practice successfully) but before the resident's transfer or discharge: An immediate transfer or discharge was required by the resident's urgent medical needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nail care was provided to one sampled resident (Resident #13) who was totally dependent upon staff for fingernail care out of 20 sampled residents. The resident's long fingernails prevented the resident from using his/her fingers to push buttons on his/her telephone. The facility census was 92 residents. Record review of the facility's Supporting Activities of Daily Living policy, revised 3/2018 showed: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. -A resident's ability to perform ADLs will be measured using clinical tools, including the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning). 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to address one sampled resident's (Resident #49) order for and documentation of a rectal (having to do with the rectum, the last six to eight inches of the large intestine that stores solid waste until it leaves the body through the anus, the opening of the rectum to the outside of the body) treatment in the absence of documentation/assessment of the resident having a rectal wound, out of 20 sampled residents. The facility census was 92 residents. Record review of the Pressure Ulcers/Skin Breakdown - Clinical Protocol policy, revised April 2018 showed: -The facility staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. -The physician will order pertinent wound treatments. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the weekly skin assessments were completed and signed by the nurse performing, that wound assessments were completed with measurements and description, and ordered treatments were performed for one sampled resident (Resident #251) out of 20 sampled residents. The facility census was 92 residents. On 3/22/22 the Administrator was notified of the past noncompliance. On 2/9/22 the facility administrator discovered skin and wound assessments and wound treatment documentation was missing, and an audit was started. On 2/21/22 a Performance Improvement Plan (PIP) was started, and nursing staff were inserviced regarding documentation of treatments, weekly skin assessments, reporting of wounds, and wound documentation, including measurements and description of wounds. The deficiency was corrected on 2/25/22. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician's orders were followed for Foley catheters (a tube with retaining balloon passed through the urethra into the bladder to drain urine), to have physician's orders for Foley catheter care for two sampled residents (Resident #29 and Resident #30); and to properly place a catheter bag during a transfer for one sampled resident (Resident #30) out of 20 sampled residents. The facility census was 92 residents. A policy was requested and the facility did not have a policy. 1. Record review of Resident #29's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Neuromuscular disorder of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the resident's physician and Registered Dietician (RD) of a significant weight loss and put interventions in place timely for one sampled resident (Resident #10) and to ensure the interventions for weight loss were being offered and implemented for two sampled residents (Resident #10 and Resident #27) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility's Nutrition and Unplanned Weight Loss Clinical Protocol revised 9/2017 showed: -The staff would report any significant weight loss to the physician. -The physician would review for medical causes of the weight loss before ordering interventions. -The physician would help identify medical conditions, medications, and oral/swallowing issues. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ongoing assessment of the resident's condition and monitoring for complications before and after hemodialysis (a procedure involving diverting blood into an external machine, where it is filtered before being returned to the body to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments, to have ongoing communication with the dialysis center, and to have individualized care plan interventions to address the resident's wishes/non-compliance related to licensed nurse assessment of his/her dialysis site for one sampled resident (Resident #49) selected for review of dialysis services, out of 20 sampled residents. The facility census was 92 residents. Record review of the facility Hemodialysis Access Care policy, revised September 2010 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's monthly Drug Regimen Review (DRR- thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) recommendations were acted on for one sampled resident (Resident #20) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility Medication Orders policy, revised November 2014 showed: -When recording orders for medication specify: --The route (the way in which a drug enters the body). --The dosage (the quantity) of the medication. --The frequency of dose administration. --The strength (the proportion of active drug substance measured in units, volume or concentration) of the medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident receiving psychotropic medications (drugs which affect psychic function, behavior, or experience) with recommendations from the pharmacist were addressed and followed-up on by the resident's physician for one sampled resident (Resident #35) out of 20 sampled residents. The facility census was 92 residents. Record review of the facility's Medication Utilization and Prescribing Clinical Protocol revised 4/18: -Based on input from the staff and resident, the physician would adjust medications based on efficacy, indications and the continued presence of clinically significant risks. -The consultant pharmacist should use the monthly and interim Drug Regimen Review (DRR) to help identify potentially problematic medications, including medication regimens that are not supported or based on clinical signs or symptoms. [...]