Wilshire at Lakewood: CPR Given to DNR Resident - MO
The resident had a do-not-resuscitate order on file. When staff found them unresponsive, without a pulse and not breathing, they started CPR anyway. By the time anyone confirmed the resident's code status, EMS had already arrived and taken over.
When facility staff told the EMS crew that the resident was a DNR, the paramedics said they had to keep going. Once emergency responders take over a resuscitation, Missouri protocol requires them to continue. They worked on the resident for some time. Their efforts failed. The resident died.
The violation was cited under F0678, which covers the obligation to honor a resident's advance directives, including the right to refuse resuscitation. Inspectors rated the harm level as minimal or potential, affecting few residents.
The staff member involved was retrained afterward, first individually and then with a group of colleagues, on how to look up a resident's code status in the facility's electronic medical record system before initiating CPR. The lesson was a simple one: check the EMR first.
A family member who held the resident's designated power of attorney, meaning they were the person authorized in writing to make medical decisions on the resident's behalf, was interviewed by inspectors. He or she said they appreciated that the facility performed CPR. They preferred staff err on the side of caution when they found someone not breathing. They were not upset. The resident, they said, was in a better place.
That a family member expressed no anger does not change what happened. The resident had made a decision, documented it, and entrusted the facility to honor it. The decision was not honored, not because anyone weighed the circumstances and made a judgment call, but because no one looked.
A DNR order is among the most deliberate choices a person can make about their own death. It requires a conversation with a physician, a signature, and a formal entry into the medical record. It is not a passive omission. It is an instruction, written down, stored in the same electronic system staff were later trained to open.
The inspection was triggered by a complaint, filed under case number 2619701. It covered three pages. The retraining happened after the fact.
The resident did not survive to know their wishes had been overridden in the final minutes of their life. The family member left the interview saying the resident was in a better place. Whether that offered any comfort about how they got there, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wilshire At Lakewood Rehab Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 31, 2026 · Our methodology
WILSHIRE AT LAKEWOOD REHAB CENTER in LEES SUMMIT, MO was cited for violations during a health inspection on November 18, 2025.
The resident had a do-not-resuscitate order on file.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.