Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at University Health Lakewood Medical Center during CMS and state inspections, most recent first.
Multiple residents with conditions such as Parkinson’s disease, stroke, diabetes, kidney disease, and mobility impairments reported that a CNA repeatedly failed to provide dignified and respectful care. The CNA allegedly refused or delayed toileting and incontinence care, told a resident to have a BM in a brief instead of using the toilet, used profane and degrading language about residents’ incontinence and weight, changed a colostomy bag in a public area, and left a resident partially naked and improperly positioned in bed. Residents also reported that the CNA ignored or dismissed call lights, refused or inadequately assisted with showers and hygiene, placed meal trays out of reach, disregarded food preferences, roughly handled belongings, and verbally stated that tasks were not his/her job or that residents expected too much. Facility leadership reported that several residents described similar concerns about the CNA’s uncaring and rude behavior.
Surveyors found numerous expired medications, supplements, and medical supplies in several medication carts, a medication refrigerator, and an OTC cabinet, including items on the 3N, 3S, 2N, and 1S units. Some products were outside their original packaging with expiration dates no longer visible. Staff interviews showed that nurses, CMTs, the ADON, and the DON were responsible for medication storage, but their descriptions of the storage checks were inconsistent, and the DON said he/she checked the carts, refrigerator, and cabinets weekly without documenting the checks or using a checklist.
The facility failed to maintain a complete infection prevention program, including a facility-specific water management program for Legionella and other water-borne pathogens, and failed to follow infection control practices during medication administration. A CMT administered eye drops and a transdermal patch without changing gloves or performing hand hygiene between routes, and an LPN did not wipe an insulin pen rubber seal with alcohol before attaching a needle. The facility also had incomplete infection surveillance logs, with missing antibiotic, lab, X-ray, and monthly tracking documentation across units.
A resident who was cognitively intact and able to make his/her own medical decisions was not invited to participate in the care plan meeting. The MDS note showed staff contacted the DPOA about scheduling, but the DPOA declined, while the resident later stated he/she had not been getting invited to care plan meetings. Staff gave conflicting accounts about whether the DPOA was enacted and who was responsible for invitations, and the MDS coordinator said no written invitation was given and documentation was inadequate.
Medication administration errors exceeded the 5% threshold after surveyors observed 2 errors in 38 opportunities. An LPN administered insulin from an insulin pen without priming it first, despite manufacturer instructions, and also measured a liquid anticonvulsant for a resident with a PEG tube using a cup marked only to 10 ml rather than an accurate syringe for the ordered 11 ml dose. The facility policy did not address insulin pens, and the DON stated nurses were expected to prime insulin pens and use a syringe for 11 ml liquid doses.
Two residents experienced physical and mental abuse from a CNA, including rough handling that caused bruising, verbal insults, refusal to assist with toileting, and being forced into a cold shower without adequate assistance. Staff and resident statements confirmed the CNA's unprofessional and abusive behavior, which violated facility policies and the residents' rights to dignity and proper care.
Staff failed to immediately report allegations of abuse and neglect involving two residents, one with dementia and one with Parkinson's disease, after witnessing or being informed of incidents of physical and verbal abuse by a CNA. Despite training and facility policy requiring prompt reporting, staff delayed notifying supervisors, allowing the CNA to continue working and potentially affecting other residents.
A resident with schizoaffective disorder and dementia was transferred to another facility after an altercation, but the LTC facility failed to document the reasons for the transfer or notify the resident's DPOA. Staff interviews revealed a lack of awareness of the facility's transfer policy, and the family member expressed dissatisfaction with the process, stating they were not informed or consented to the transfer.
A facility failed to provide a resident and their DPOA with an emergency discharge letter, including appeal rights and Ombudsman contact information. The resident, with severe cognitive impairment and mental health diagnoses, was transferred without proper notification. Interviews revealed staff were unaware of the process for issuing such notices, and the facility did not notify the Ombudsman of the transfer.
A resident with RSV was on contact droplet isolation, but a CNA entered the room without proper PPE or hand hygiene, leaving the door open. The CNA was unsure if isolation was still required, and the LPN confirmed the resident was still on isolation. The ADON and DON expected staff to follow infection control procedures, which were not adhered to in this instance.
The facility failed to notify residents and their responsible parties of roommate changes, violating residents' rights. Three residents experienced roommate changes without proper verbal or written notifications, contrary to facility policy. Staff interviews revealed inconsistent practices and misunderstandings regarding notification requirements.
A resident's discharge notice contained incorrect contact information for the DHSS Appeals Unit and omitted required details for the Missouri Protection and Advocacy Agency. This error was identified during the appeal process, leading to the dismissal of the 30-day discharge notice. The facility's policy requires proper notification in accordance with regulations.
Failure to Provide Dignified, Respectful Care by CNA
Penalty
Summary
The deficiency involves multiple instances in which a certified nurse aide (CNA A) failed to treat residents with dignity and respect and did not provide care in a manner that maintained or enhanced their quality of life. One resident with Parkinson’s disease, osteoarthritis, diabetes, impaired balance, and frequent incontinence reported that after asking to use the bathroom in the evening, CNA A refused to assist with toileting, stated that his/her back hurt, and told the resident to have a bowel movement in his/her brief instead of using the toilet. The resident stated that CNA A knew a bowel movement occurred in the brief and that the brief was not changed until the next morning. The same resident reported that on another occasion, while the resident was still having a bowel movement, CNA A commented, “You are still shitting on yourself,” and frequently used terms such as “shit” and “piss” when referring to the resident’s and roommate’s incontinence, which made the resident feel worse about his/her loss of independence. Another resident, who was cognitively intact, wheelchair-bound, and dependent on staff for most cares including colostomy and catheter management, reported that CNA A was abrasive, uncooperative, and argumentative, often saying he/she did not feel like performing requested tasks such as taking the resident to the bathroom. This resident stated that CNA A once changed his/her colostomy bag in front of others at the nurses’ station, which the resident found humiliating, and that on another occasion CNA A failed to take the resident to the bathroom and later falsely claimed to other staff that the task had been completed. A resident with expressive/receptive aphasia, severe cognitive impairment, and a history of stroke, who was normally continent but temporarily on strict bedrest due to severe leg swelling, reported that CNA A repeatedly responded to call lights without providing needed incontinence care, resulting in the resident being found wet through his/her brief, clothing, bedding, and with urine on the floor. When directed by a nurse to provide care, CNA A reportedly raised the bed, threw the resident’s blankets on the floor, left the resident naked and half hanging off the high bed with an unsecured brief and no sheets, refused to lower the bed, and stated, “You’re too fat and I ain’t gonna do you no more,” and “You’re too heavy,” before leaving. The resident also reported that CNA A routinely ignored preferences for meals, brought unwanted food, became angry when it was not eaten, turned off call lights without returning, and became upset when the resident took time to express him/herself. Additional residents described similar patterns of disrespectful and unhelpful behavior by CNA A. One resident who used an electric wheelchair, had diabetes, Parkinson’s disease, chronic kidney disease, and required extensive assistance for transfers and toileting reported that CNA A initially placed a meal tray on a table out of reach, refused to give his/her name to avoid being reported, frequently complained of being tired, told the resident, “You expect too much,” left the resident on the toilet without returning, and later ordered the resident to “turn the damn light off” when the call light was used to request help. Another resident, cognitively intact and dependent on staff for transfers, toileting hygiene, and shower assistance, stated that CNA A refused or inadequately washed his/her legs, back, and feet during showers, did not make the bed properly or use fitted sheets, failed to respond to call lights, and repeatedly claimed to be too busy or too tired to provide care. A further cognitively intact resident who was mostly independent but occasionally incontinent reported that CNA A was “horrible and very mouthy,” was observed answering the call light phone at the nurses’ station and hanging up while saying, “That’s not my job,” refused to change sheets on shower days, threw meal plates down in front of residents, and was neither patient nor kind. During the facility’s investigation, the Administrator and DON stated that multiple residents reported similar concerns about CNA A being uncaring and unhelpful, and that CNA A had prior write-ups for rude demeanor, while CNA A denied all allegations. These combined accounts show that CNA A’s actions and inactions included refusing or delaying toileting and incontinence care, using degrading and profane language about residents’ bodily functions and weight, exposing a resident’s colostomy care in a public area, leaving a resident partially naked and improperly positioned in bed, ignoring or dismissing call lights, failing to assist with hygiene tasks the residents could not perform, disregarding residents’ meal preferences, and handling residents’ belongings roughly. These behaviors directly conflicted with the facility’s abuse and neglect policy requiring staff to prevent verbal or nonverbal conduct that could cause humiliation, intimidation, fear, shame, agitation, or degradation, and resulted in multiple residents reporting that they felt humiliated, disrespected, and that CNA A did not want to care for them.
Expired and Improperly Stored Medications Found in Multiple Medication Areas
Penalty
Summary
The facility failed to ensure that drugs, biologicals, and related medical supplies were stored and labeled in accordance with accepted professional principles. During observation of multiple medication carts, a medication refrigerator, and an OTC cabinet, surveyors found numerous expired items and medications that had been removed from their original packaging with expiration dates no longer visible. These items were located in the 3N CMT medication cart, the 3N short hall licensed nurse medication cart, the 3N medication refrigerator, the 3S short hall licensed nurse medication cart, the 2N OTC cabinet, and the 1S medication cart. On the 3N CMT cart, surveyors observed Culturelle capsules, guaifenesin ER tablets, and Allegra tablets outside their original packaging with expiration dates not visible. On the 3N short hall cart, surveyors found disinfecting port protectors, two tubes of Nystatin ointment, Benadryl cream, hemorrhoidal ointment, opened and unopened Xeroform dressings, povidone iodine swab sticks, lubricating jelly, and Telfa pads, all expired. The 3N medication refrigerator contained a bottle of mouth rinse solution with a beyond use date of 8/2/25. On the 3S short hall cart, surveyors found expired betadine solution, disinfecting port protectors, and Dulcolax suppositories. Additional expired items were found in the 2N OTC cabinet, including Robafen CF, D3-50, Benadryl cream, terbinafine cream, ear wax removal drops, and multi-vite liquid/mineral supplement. The 1S medication cart contained an expired AREDS 2 bottle and an expired ear wax removal aid. Staff interviews showed that nurses, CMTs, the ADON, and the DON were responsible for medication storage, but staff gave inconsistent descriptions of how often carts were checked and whether a specific system existed. The DON stated he/she checked all medication carts, refrigerators, and cabinets each Monday but did not document or use a checklist, and staff were unaware of that system.
Incomplete Infection Prevention Program and Medication Administration Breaks
Penalty
Summary
The facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program for Legionella and other water-borne pathogens. The Water Management Program policy, last revised 10/12/23, did not include a CDC toolkit assessment with control measures such as physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. A completed CDC Legionella Environmental Assessment Form was missing, and there was no facility-specific infection prevention program or plan to address outbreaks of Legionella or other water-borne pathogens. The policy also stated the program would be reviewed annually, while the document metadata listed the next review as 10/12/26. The facility had a sprinkler system supplied by the local water company, a sprinkler riser room serving the whole facility, mop/service sinks, water heaters, resident room sinks and bathrooms, bathhouses, dining room sinks, ice machines, and steam tables throughout the building. The facility also failed to ensure appropriate hand hygiene and infection control practices during medication administration. One resident had diagnoses of DM II with hyperglycemia and CKD stage 5 and was ordered Refresh Tears ophthalmic solution. During medication administration, a CMT sanitized hands, entered the room, put on gloves, administered oral medications, and then gave the eye drops with the same gloved hands before removing gloves. Another resident with Parkinson's disease was ordered an Aspercreme Lidocaine patch. During medication administration, the same CMT sanitized hands, prepared the medication, put on gloves, administered oral medications, and then applied the patch with the same gloved hands before removing gloves and sanitizing hands. Staff interviews confirmed the CMT did not perform hand hygiene correctly and should have removed gloves, sanitized hands, and put on new gloves between different routes of administration. The facility further failed to follow its insulin injection procedure for another resident with DM II who was ordered Insulin Lispro Junior KwikPen 10 units with meals. During observation, an LPN removed the cap from the insulin pen, did not wipe the rubber seal with alcohol, attached a needle, dialed the dose, and administered the insulin. The facility policy required the rubber cap to be swabbed with alcohol before attaching the needle. The LPN acknowledged not wiping the seal and stated it was because he/she was nervous while being observed. In addition, the facility's infection control surveillance logs were incomplete and did not contain the required monthly tracking, antibiotic reports, lab or X-ray results, or other documentation across multiple units and months. The IP stated the tracking material was what the prior IP had left and knew it was incomplete, while the DON stated the infection tracking book should have included maps, required reports, monitoring criteria, lab and X-ray results, antibiotic lists, and education when trends were identified.
Resident Not Invited to Care Plan Meeting
Penalty
Summary
The facility failed to ensure that one sampled resident was invited to participate in the development and implementation of the person-centered plan of care. Resident #31 was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and the annual MDS showed the resident was cognitively intact. An MDS note documented that the MDS Coordinator contacted the resident’s DPOA about scheduling a care plan meeting, and the DPOA declined a meeting at that time. During interviews, the resident stated he/she had not been getting invited to care plan meetings and could make his/her own medical decisions. Staff gave conflicting accounts about who was responsible for invitations and whether the resident’s DPOA had been enacted. The MDS Coordinator said the resident was his/her own person, initially declined a care plan meeting, later asked that a family member be invited, and that no written invitations were given; the coordinator also stated he/she dropped the ball and should have documented a better note. Other staff and the DON stated the resident was his/her own person and should have been invited to the care plan meeting, with the DON noting that all residents who were their own responsible party should be invited.
Medication Administration Errors Exceeded 5% Threshold
Penalty
Summary
The facility failed to ensure medication administration errors remained below a 5% rate. Surveyors observed 2 medication errors in 38 opportunities, resulting in a 5.26% error rate. One error involved an LPN administering insulin lispro from an insulin pen to a resident with type 2 diabetes mellitus without first priming the pen with 2 units, as required by the manufacturer’s instructions. The facility’s Insulin Injection Administration policy dated 11/11/23 did not address insulin pens, and the DON stated the facility practice was to prime all insulin pens with one unit of insulin. A second error involved a resident with a PEG tube who had an order for levetiracetam oral solution 100 mg/ml, 11 ml via PEG tube every 12 hours. The LPN measured the medication in a graduated cup by pouring it slightly above the 10 ml line because the cup did not have an 11 ml marking, and then administered it through the PEG tube. During interview, the LPN stated this was how the medication had always been measured and acknowledged a syringe could have been used to measure 11 ml accurately. The DON stated licensed nurses were expected to use a syringe to measure 11 ml of a liquid medication.
Failure to Prevent Physical and Mental Abuse by CNA
Penalty
Summary
The facility failed to protect two residents from physical and mental abuse by a Certified Nurse Aide (CNA). One resident, who had severe cognitive impairment due to dementia and a history of stroke, was subjected to rough handling by the CNA, resulting in visible bruising on the resident's right forearm. Multiple staff statements and interviews indicated that the CNA used foul and derogatory language towards the resident, refused to assist with toileting, and told the resident to be quiet. The resident was left in a wet brief and required assistance from other staff for toileting throughout the day. Observations confirmed the presence of bruising consistent with fingertip marks on the resident's arm, and the resident reported pain and distress from the incident. Another resident, who was cognitively intact but had Parkinson's disease and required assistance with activities of daily living, was also mistreated by the same CNA. The CNA forced the resident into a cold shower despite the resident's request to let the water warm up, provided minimal assistance with washing, and left the resident partially naked and alone in the shower room for several minutes. The resident was heard crying and calling for help during this time. Staff interviews and resident statements corroborated that the CNA was verbally abusive, rushed the shower process, and failed to provide adequate care and dignity during the incident. Both incidents were witnessed or reported by other staff members, some of whom delayed reporting due to fear of retaliation or uncertainty about the events. The CNA involved had received prior training on abuse and neglect, and staff accounts consistently described the CNA's behavior as rough, disrespectful, and unprofessional throughout the shift. The facility's policies prohibit such conduct, and the actions of the CNA directly violated the residents' rights to be free from abuse and to receive care with dignity and respect.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations in accordance with its own policy for two residents. In both cases, staff members witnessed or were made aware of incidents involving a Certified Nurse Aide (CNA) who allegedly engaged in abusive behavior, including physical and verbal abuse, but did not immediately report these incidents to the appropriate authorities or supervisors. The CNA was allowed to continue working after the alleged incidents, potentially affecting all residents under their care. One resident, who had severe cognitive impairment due to dementia, was reportedly grabbed forcefully on the arm by the CNA, resulting in visible red marks and pain that lasted for days. The resident expressed distress immediately after the incident, and staff present at the time observed the resident's upset state and physical marks. Despite being trained to report such incidents, the staff did not immediately communicate their suspicions to the charge nurse or administration, citing reasons such as being unsure of what had happened, assuming others would report, or being in shock. Another resident, who was cognitively intact and diagnosed with Parkinson's disease, experienced verbal abuse and was subjected to a cold shower against their wishes, causing emotional distress and physical discomfort. The resident was left alone and naked in the shower room for an extended period and reported the incident to staff afterward. Again, the staff member who witnessed or was informed of the incident did not report it immediately, only disclosing the details the following day when prompted by a supervisor. Interviews confirmed that staff had received training on abuse and neglect reporting, and facility policy required immediate reporting, but this protocol was not followed in these cases.
Failure to Document and Notify in Resident Transfer
Penalty
Summary
The facility failed to ensure proper documentation and notification procedures were followed during the discharge of a resident to another facility. The resident, who had a history of schizoaffective disorder and dementia with agitation, was involved in an altercation with another resident. Following this incident, the facility decided to transfer the resident to another facility that could better accommodate their needs. However, the facility did not document the reasons for the transfer, the attempts made to meet the resident's needs, or notify the resident's Durable Power of Attorney (DPOA) as required by their policy. Interviews with facility staff revealed a lack of awareness and adherence to the facility's transfer and discharge policy. The Social Services Designee (SSD) and Social Services Worker (SSW) were involved in finding a new placement for the resident but failed to document communications with the DPOA or provide written notice of the transfer. The Administrator admitted to not being aware of the requirement to provide written notice to the resident or family member, and there was no evidence of a 30-day notice or emergency notice being given. The resident's family member/DPOA expressed dissatisfaction with the process, stating they were not informed of the transfer plans and did not consent to the move. The family member was only given a short notice to pick up the resident, which they found unacceptable. The facility's failure to document the transfer process and notify the responsible party led to a deficiency in meeting regulatory requirements for resident transfers.
Failure to Provide Emergency Discharge Notification and Appeal Rights
Penalty
Summary
The facility failed to provide an emergency discharge letter to a resident and their Durable Power of Attorney (DPOA), which included the right to appeal the discharge and contact information for the Ombudsman. This deficiency was identified for one resident out of a sample of five, in a facility with a census of 147 residents. The resident in question was admitted with diagnoses including schizoaffective disorder, bipolar type, and dementia with agitation, and was severely cognitively impaired according to their Minimum Data Set (MDS). The facility's policy on transfers and discharges requires proper notification and assistance to residents and families, including documentation of the basis for transfer, attempts to meet resident needs, and services available at the receiving facility. However, in this case, there was no documentation of communication with the resident's DPOA regarding the proposed transfer, the reason for the transfer, or the resident's rights to appeal. The resident was transferred to another facility without a written notice or appeal rights being provided. Interviews with facility staff, including the Social Services Designee, Social Service Worker, Administrator, and Business Office Manager, revealed a lack of awareness and process for providing written notification of transfers or discharges. The Administrator admitted that the facility did not provide a 30-day notice or an emergency notice of discharge, and the Business Office Manager confirmed that the facility typically only issued notices for non-payment. The facility also failed to notify the Ombudsman of the resident's proposed transfer.
Infection Control Breach for Resident on Isolation
Penalty
Summary
The facility failed to adhere to infection control practices for a resident who was on contact droplet isolation due to a positive test for Respiratory Syncytial Virus (RSV). The resident, who had a history of diabetes, balance disorder, anemia, schizophrenia, and myeloma, was placed on isolation after exhibiting symptoms such as cough, lethargy, and a low-grade fever. Despite the isolation order, the resident's room door was observed to be open, and a Certified Nursing Assistant (CNA) entered the room without wearing the appropriate personal protective equipment (PPE) or performing hand hygiene. The CNA, upon entering the resident's room, wore only a mask and did not don gloves or a gown, nor did they wash or sanitize their hands before or after the visit. The CNA later admitted to not being sure if the resident was still on isolation and acknowledged the failure to follow proper procedures. The Licensed Practical Nurse (LPN) confirmed that the resident was still on isolation and that the door should have remained closed, but it was left open due to the resident's high fall risk. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that staff were expected to follow the infection control procedures, including wearing the appropriate PPE and performing hand hygiene. However, the CNA did not comply with these expectations, leading to a breach in infection control protocols. The facility's policy required that staff wash or sanitize their hands before donning gloves and gowns and discard them appropriately before leaving the isolation room.
Failure to Notify Residents of Roommate Changes
Penalty
Summary
The facility failed to provide timely notifications to residents and their responsible parties regarding roommate changes, violating the residents' rights to be informed of such changes. This deficiency was identified for three residents out of a sample of five, where the facility did not provide either verbal or written notifications prior to the changes. The facility's policy mandates immediate notification to the resident and their representative when there is a change in room or roommate assignment, but this was not adhered to in the cases reviewed. For one resident, the family member and Durable Power of Attorney (DPOA) expressed upset upon discovering a new roommate without prior notification. The resident's progress notes lacked documentation of any verbal or written notification to the DPOA before the new roommate was admitted. Interviews with staff revealed a misunderstanding of the notification requirements, with some staff believing that notification was not necessary if the resident was in a semi-private room. Another resident's DPOA was verbally notified of room changes but did not receive written notifications as required. Similarly, a third resident was moved to a different unit upon returning from the hospital without documented notification to the DPOA. Staff interviews indicated a lack of consistent practice in notifying both the resident being moved and the resident receiving a new roommate, with verbal notifications often undocumented and written notifications not provided at all.
Incorrect Contact Information on Discharge Notice
Penalty
Summary
The facility failed to ensure that a resident's discharge notification contained the correct contact information for appeal rights. This deficiency was identified for one resident out of a sample of five, in a facility with a census of 149 residents. The issue arose when the discharge notice, dated 10/31/23, was sent to the resident's Durable Power of Attorney (DPOA) with incorrect contact information for the Department of Health and Senior Services (DHSS) Appeals Unit. Additionally, the notice did not include the required contact information for the Missouri Protection and Advocacy Agency, which is necessary for Medicare and Medicaid certified facility residents with developmental disabilities. The deficiency was discovered during the resident's appeal process, leading to the dismissal of the 30-day discharge notice due to the incorrect contact information. The facility's policy on transfers and discharges, dated 3/5/19, mandates proper notification and assistance to residents and families in accordance with federal and state-specific regulations. The error in the discharge notice was confirmed during interviews with the Operations Coordinator and the Administrator, who acknowledged the incorrect contact information and the subsequent discovery during the appeals process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seasons Rehab And Healthcare Center | 0.5 mi | ★★★★★ | 2 | 0 |
| Wilshire At Lakewood Rehab Center | 1.3 mi | ★★★★★ | 16 | 0 |
| Edgewood Manor Health Care Center | 2.9 mi | ★★★★★ | 6 | 0 |
| John Knox Village Care Center | 4 mi | ★★★★★ | 0 | 0 |
| Monterey Park Rehabilitation & Health Care Center | 4.5 mi | ★★★★★ | 13 | 0 |
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