Wilshire at Lakewood Rehab Center

In the surveyor’s words

From the most serious findings on record at Wilshire at Lakewood Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Apr 12, 2022

  Based on interview and record review, the facility failed to contact Emergency Medical Services (EMS), check code status, initiate and provide continuous cardiopulmonary resuscitation (CPR) for one sampled resident (Resident #1) who had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Agency Licensed Practical Nurse (LPN) A, Agency LPN B, and Agency Certified Medication Technician (CMT) A failed to verify the resident's code status and provide CPR. The facility census was 108 residents. On [DATE] at 12:57 P.M. the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on [DATE]. On [DATE] the facility administration was notified of the incident and the investigation was started. No employees were allowed to work prior to reeducation. […]

• Actual harm, isolatedF689Mar 22, 2022

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Nov 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 21, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 7, 2022

  Based on observation, interview and record review, the facility failed to keep the kitchen walls and ice maker clean; to maintain temperature logs for all refrigerators; to properly store leftover items in the refrigerator; and to properly document food temperatures to ensure they were thoroughly cooked and being held at an appropriate temperature on the steamtable. The facility census was 114 residents. Record review of the facility's undated but copyrighted 2022 policy titled Food Preparation Guidelines showed food and drinks should be palatable, attractive and at a safe and appetizing temperature. Strategies to ensure resident satisfaction included serving hot foods hot. 1. Observation on 11/1/22 at 10:15 A.M. […]