Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Wilshire At Lakewood Rehab Center during CMS and state inspections, most recent first.
Surveyors found infection control failures during resident care and in the facility’s water management program. The facility had incomplete Legionella assessment materials and water management documentation, while staff did not use a barrier when placing blood sugar supplies in a resident care area, a CMT failed to perform hand hygiene before, during, and after medication administration, and an LPN did not sanitize insulin pen hubs before use for two residents with DM II.
A resident with a physician's order for Do Not Resuscitate (DNR) was found unresponsive and without a pulse. The charge nurse initiated a Code Blue and started CPR without first confirming the resident's code status in the electronic medical record. EMS arrived and continued resuscitation efforts, only learning of the DNR order after arrival. Despite advanced interventions, the resident remained in asystole and resuscitation was eventually discontinued.
A resident with an ileostomy had the pouch taped shut when staff could not find a closure clamp, and the resident said this interfered with emptying the pouch and learning self-care. In a separate issue, a resident with ESRD and dialysis dependence had an order entry error for daily weights, with multiple missing weights and staff documenting refusals on the TAR instead of charting refusals in a progress note; leaders stated the order should have been clarified and the resident should have been weighed daily.
A resident with stroke history and protein-calorie malnutrition had significant weight loss, and the RD ordered Boost or Boost Breeze three times daily. The resident reported drinking Ensure brought from home, while staff were unaware of the home supplements and did not document the ordered supplement or the amount consumed on the MAR/TAR. The DON, an LPN, and a CMT all indicated that supplement administration and intake should have been documented.
Two residents with PEG/G-tubes did not receive proper tube placement verification before use. An LPN used auscultation and residual checks for one resident, and another LPN checked only for residual before giving G-tube meds to a resident with a G-tube order set. The DON and ADON stated staff had been using outdated methods and that placement should have been checked with pH-based verification after residual was obtained.
A facility failed to keep its medication error rate below 5% after an observed G-tube med pass showed two errors in 28 opportunities. An LPN crushed and mixed an Ibuprofen tablet and Gabapentin capsule for a resident with a G-tube, then administered the meds without ensuring the full dose was delivered; medication remnants were left in the cup. The DON and ADON stated the meds were not given appropriately and that additional water should have been used to clear the cup.
Open Dumpster Lids and Overflowing Refuse: Surveyors observed outdoor dumpsters with lids left open on multiple occasions, including a south dumpster with both lids flipped back open and later overflowing with boxes. The Administrator stated dumpster lids should be kept closed at all times, and the DPO acknowledged the lids should not be left open and said housekeeping, dietary, and maintenance frequently used the dumpsters.
Infection Control Lapses During Blood Glucose Checks, Medication Passes, and Insulin Pen Use
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program related to Legionella and other water-borne pathogens, and surveyors also observed multiple infection control lapses during resident care. The facility had a water management program binder that included CDC toolkit materials, incomplete Legionella environmental assessment forms, a facility-specific review with a limited layout map, a glossary, educational materials, and water test results from January 2024 through September 2025. During interviews, the Administrator said the water management program was created using the assessments they follow and assumed they had all been finished, while the DPO said the program was based on a TELS review and that missing assessments were not caught. During blood glucose monitoring for a resident with DM II, an LPN entered the room and placed blood sugar supplies on the resident’s sink area without a barrier in place before checking the blood sugar. The LPN then gathered the supplies and left the room. The LPN stated he/she would not have done anything differently and had never been taught that a barrier was needed when setting down blood sugar supplies in resident care areas. The DON later stated that a barrier needed to be in place when setting any medical equipment down in a resident care area, including blood sugar monitoring supplies, and that the LPN had not performed correct infection control measures. During medication administration for a resident with DM II and acute kidney failure, a CMT did not wash or sanitize hands before taking medications out of packets, entered the resident’s room without hand hygiene, exited without hand hygiene, and began the next resident’s medication administration without hand hygiene. The CMT said he/she would not have done anything differently and was unsure whether hand hygiene had been performed. In addition, during insulin administration for two residents with DM II, an LPN checked each resident’s blood sugar, exited the room, prepared insulin via a pen injector, placed the needle on the pen without sanitizing the hub of the pen, primed the pen, dialed the ordered dose, and then re-entered the room to administer the insulin. The LPN said he/she would not have done anything differently, and the DON and ADON both stated that insulin pens needed to be sanitized before each use and that the LPN had not performed correct infection control measures.
Failure to Honor DNR Order During Cardiac Arrest
Penalty
Summary
The facility failed to follow a physician's order for no cardiopulmonary resuscitation (DNR) for a resident who was found unresponsive, not breathing, and without a pulse. Despite the presence of a DNR order in the resident's medical record, the licensed nurse on duty initiated a Code Blue and began CPR upon discovering the resident's condition. Emergency Medical Services (EMS) were called and arrived to find CPR in progress, with the resident unresponsive and showing signs of lividity. Facility staff reported to EMS that the resident was a full code, and CPR efforts continued, including advanced interventions such as airway management, medication administration, and use of mechanical chest compression devices. The EMS team was informed of the resident's DNR status after arrival, but stated they could not stop resuscitation at that point. The resident remained in asystole throughout the resuscitation efforts, and after 25 minutes of advanced cardiovascular life support, resuscitation was discontinued. Interviews with facility staff revealed that the charge nurse did not confirm the resident's code status in the electronic medical record before initiating CPR. The nurse later acknowledged being retrained to check code status prior to starting resuscitation. The resident's family member expressed understanding and was not upset by the actions taken. The deficiency centers on the failure to adhere to the resident's DNR order at the time of the emergency.
Taped Ileostomy Pouch and Uncorrected Daily Weight Order Error
Penalty
Summary
The facility failed to meet professional standards of quality when staff taped shut a resident’s ileostomy pouch instead of using a closure clamp. The resident was admitted with ileostomy status, was cognitively intact, and had an ileostomy noted in the admission record. The resident stated that staff were not good about keeping needed supplies in the room and was upset that the pouch had to be taped shut because a clamp could not be found. Observation showed the ileostomy bag taped shut, and the resident said this prevented him/her from emptying the pouch and interfered with learning to do his/her own ileostomy care. During interview, the LPN said he/she could not find a clamp or closure device during ostomy care and therefore taped the pouch shut. The LPN also stated staff had trouble keeping a good seal when the resident was first admitted and that supplies had been used up. The DON said the facility had plenty of ostomy supplies and that all nursing staff had access to central supply. The ADON stated ostomy pouches should never be taped shut and that the pouch should have been laid on a towel while a closure device was obtained from central supply. The facility also failed to correct an order entry error related to daily weights for a resident with ESRD and dialysis dependence. The resident’s order summary showed an order to weigh daily, but the order had a start date later than its date entered. Review of the record showed missing daily weights, with weights documented only on dialysis days in August and multiple missing weights in September. Staff marked several missed weights as drug refused on the TAR, although the Regional Nurse, ADON, DON, Medical Director, and ADON all stated that refusals should have been documented in a progress note and that the weight order should have been clarified. The Medical Director stated the resident should have been weighed daily since admission.
Failure to Document Ordered Nutritional Supplement Intake
Penalty
Summary
The facility failed to ensure staff adequately documented supplement usage for one resident with a history of cerebral infarction, unspecified protein-calorie malnutrition, ulcerative colitis, and diverticulosis. The resident’s admission MDS showed cognitive intactness and no known weight loss prior to admission, but the care plan identified a nutritional problem related to a mechanically altered diet and included monitoring weight and providing the ordered diet. The RD later documented a 6.3% weight loss since admission and recommended Boost or an equivalent supplement three times daily. The resident’s order summary showed an order for Boost or Boost Breeze three times daily. During interview, the resident stated that family brought supplements from home and stored them in the mini fridge, that the resident had already consumed two Ensure drinks on one day because breakfast was not liked, and that the resident had been drinking Ensure since admission without staff asking how much was consumed. Observation also showed the resident drinking an 8-ounce Ensure supplement. The DON stated she was unaware the resident had been drinking supplements brought from home and expected staff to document when supplements were given and how much was consumed if ordered. Review of the MAR/TAR for September showed staff had not documented that the resident received the ordered Boost supplement or the amount consumed. An LPN stated staff usually document when a supplement is given and how much is drank, but was unsure why documentation was not occurring. A CMT stated that regardless of who provided the supplement, staff would need to document administration and intake, and that the resident’s preferred supplement should be reviewed with the RD if different from the ordered product.
Improper PEG/G-tube Placement Verification
Penalty
Summary
The facility failed to ensure appropriate care for residents with feeding tubes by not properly assessing PEG/G-tube placement before use. Resident #17 had a PEG tube and diagnoses including dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, and encounter for surgical aftercare following surgery on the digestive system. The resident’s care plan and orders required tube feeding, checking tube placement and gastric residuals per facility protocol, monitoring for complications, and providing local PEG site care. During observation, tube feeding was running and the PEG site showed no redness or open areas. When an LPN assessed the tube, he/she injected air and listened with a stethoscope, then checked residual and obtained zero ml. Resident #149 was admitted with a diagnosis of gastrostomy and had orders for residual checks every shift if over 50 ml during feeding, medication administration, or flushes, along with flush orders and medications to be given via G-tube. The resident’s care plan contained no focus, goal, or interventions for the G-tube. During observation of medication administration, an LPN prepared ibuprofen and gabapentin for G-tube administration, checked residual with a syringe, obtained no residual, did not use any other method to verify placement, and then administered the medications. Interviews showed staff were using auscultation and residual checks as their method for PEG/G-tube placement verification. The DON stated the facility had recently found that PEG tubes were not being assessed correctly and that, prior to the survey, the expectation was to auscultate and check residual. The DON also stated that if no residual was obtained, the physician should be contacted for a KUB to check placement. The ADON stated staff were expected to check placement using pH strips after obtaining residual, that the policy was being updated, and that staff had not administered medications appropriately if they had not checked for appropriate placement.
Medication Administration Error During G-Tube Medication Pass
Penalty
Summary
The facility failed to ensure a medication error rate under 5% for one supplemental resident out of five supplemental residents. Two medication errors were identified during 28 observed opportunities, resulting in an error rate of 7.14%. The resident involved had a G-tube and orders for residual checks, water flushes before and after medication administration, and flushing between medications. The resident also had orders for Gabapentin 400 mg via G-tube twice daily for neuropathy and Ibuprofen 200 mg four times daily for inflammation. During observation of the resident's G-tube medication administration, an LPN placed the Ibuprofen tablet and the contents of the Gabapentin capsule into a medication cup, then transferred them into a small bag to be crushed together and returned the crushed medications to the cup with water. The LPN then flushed the G-tube with 30 ml of water, poured the medications into the syringe, and flushed again with 30 ml of water, but did not ensure all medication was given. When the medication cup was checked shortly after, medication remnants were still present in the cup. The LPN stated he/she would not have done anything differently, while the DON and ADON stated the medications were not administered appropriately and that additional water should have been added to the cup to ensure the full dose was received.
Open Dumpster Lids and Overflowing Refuse
Penalty
Summary
The facility failed to properly contain waste and refuse in outdoor dumpsters, with dumpster lids observed left open during multiple survey observations. On 9/15/25, the south lid of the south dumpster outside the Service Hall was observed flipped back completely open, and the facility had large wooded areas on the north and west sides. On 9/17/25, during a walk-through with the DPO, the south dumpster had both lids flipped back open and the north dumpster had its north lid flipped back. Later that day, the south dumpster was observed overflowing with boxes and still had both lids flipped back open, while the north dumpster again had its north lid flipped back. On 9/19/25, the north lid of the north dumpster was again observed flipped back open during the concluding outer perimeter inspection. During interview, the Administrator stated dumpster lids should be kept closed at all times and that all departments use the dumpsters. The DPO stated housekeeping, dietary, and maintenance frequently use the dumpsters, that he/she knew the lids should not be left open, and that they had closed them at least eight times during the survey, including the morning before when it was raining.
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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 Lees Summit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Health Lakewood Medical Center | 1.3 mi | ★★★★★ | 12 | 0 |
| Seasons Rehab And Healthcare Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Monterey Park Rehabilitation & Health Care Center | 3.7 mi | ★★★★★ | 13 | 0 |
| Ignite Medical Resort Blue Springs | 3.9 mi | ★★★★★ | 0 | 0 |
| Edgewood Manor Health Care Center | 4.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.