University Health Lakewood Medical Center

In the surveyor’s words

From the most serious findings on record at University Health Lakewood Medical Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 30, 2025

  Based 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. […]

• Actual harm, isolatedF600Nov 30, 2022

  Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free of abuse when Resident #2 who had a history of aggressive behaviors struck the resident on the side of his/her face, causing ecchymosis (bruising) and a fractured to his/her right finger out of three sampled residents. The facility census was 157 residents. Record review of the facility's Abuse and Neglect policy dated 8/1/27 showed: -The facility would prohibit abuse, neglect, misappropriation of resident property, and exploitation for all residents. -Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, injury or mental anguish. […]

• No harm, potential for more than minimal, widespreadF761Aug 22, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Aug 22, 2025

  Based 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)… […]

• No harm, potential for more than minimal, patternF557Mar 20, 2026

  Based 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. […]