Inspection Reports for Lakepoint Wichita, LLC

The visit included complaint investigations numbered 183375, 188093, 188529, 190272, 190241, 190753, and 192504.

The facility was found deficient in multiple areas including failure to revise negotiated service agreements after significant changes in resident service needs, failure to safeguard resident records from theft or unauthorized use, incomplete documentation of incidents and follow-up in resident records, lack of quarterly reviews of the emergency management plan with staff and residents, and failure to comply with tuberculosis screening guidelines for new residents.

The facility was found deficient in multiple areas including failure to promote resident dignity, failure to provide required Medicaid/Medicare notices, failure to notify the Long Term Care Ombudsman of a resident's discharge, failure to ensure adequate supervision and accident hazard prevention, failure to provide appropriate catheter care and infection control precautions, failure to complete trauma-informed care assessments, failure to ensure proper drug regimen review and documentation, failure to label and store medications properly, failure to coordinate hospice care, failure to submit accurate staffing data, and failure to maintain an effective infection prevention and control program.

The Plan of Correction addresses multiple deficiencies including resident rights, Medicaid/Medicare notices, discharge notices, accident hazards, catheter care, trauma informed care, drug regimen reviews, psychotropic medication use, medication labeling and storage, hospice services coordination, payroll based journal compliance, and infection prevention and control.

The visit was triggered by complaint investigations KS00189461 and KS00189424. The facility was found non-compliant in preventing falls and ensuring resident safety.

The facility failed to provide a safe environment for a cognitively impaired resident with a history of multiple falls, resulting in repeated falls including one that caused a fractured wrist. The facility lacked adequate interventions, toileting plans, and root cause analyses to prevent further falls.

The plan addresses corrective actions for residents requiring 1-hour assistance while awake and bowel and bladder care programs following a fall with fracture. The facility outlines measures to identify other residents at risk and monitor compliance through care plan reviews and root cause analysis.

The inspection findings represent the results of investigations of complaints #182988, 181851, 181971, 182563, and 182648.

The facility failed to provide bathing opportunities as per resident preferences for three residents and failed to administer medications as ordered for one resident, including narcotic pain medication and antibiotics. Documentation of bathing and medication administration was inconsistent and did not always reflect actual care provided.

The facility was cited for deficiencies related to ADL care for dependent residents and pharmacy services/procedures, specifically regarding documentation of showers and medication administration. The Plan of Correction outlines training and auditing measures to address these deficiencies.

The inspection included complaint investigations numbered 163931, 166640, 167862, 170490, 171473, 171521, 172312, 174433, 175944, 177122, 179975, 180047, 180574, 181776.

The facility was found deficient in multiple areas including inaccurate functional capacity screening, incomplete negotiated service agreements, inadequate health care services coordination, lack of proper medication self-administration assessments, improper medication storage, incomplete resident incident documentation, failure to conduct quarterly emergency management plan reviews with residents, and non-compliance with tuberculosis screening requirements for new employees.

The inspection was triggered by multiple complaint investigations KS00178024, KS00177983, KS00175604, KS00175094, and KS00174283.

The facility was found deficient in multiple areas including failure to provide dignified care during meals and basic cares, failure to issue timely Medicaid notifications, failure to maintain a homelike environment, failure to provide timely transfer/discharge notices, failure to transmit discharge MDS, failure to revise care plans for falls and dementia, failure to assist with hearing aids, failure to provide bathing for dependent residents, inconsistent weekend activities and lack of certified activity professional, failure to maintain range of motion and proper positioning, failure to prevent accidents including improper gait belt use resulting in a fall with fracture, failure to monitor and respond to weight loss, failure to provide consistent dementia care, failure to identify and report medication irregularities, failure to properly store and label medications, failure to maintain food safety and hand hygiene, failure to maintain infection control practices, failure to have a certified infection preventionist, and failure to obtain and document influenza and pneumococcal vaccinations.

The facility identified multiple deficiencies related to resident rights, Medicaid/Medicare notices, environment, care planning, activities, infection control, medication management, and dementia care. The plan outlines corrective actions including staff education, audits, care plan revisions, and monitoring through QAPI to achieve substantial compliance by 04/21/2023.

The administrator failed to ensure disaster and emergency preparedness by not performing quarterly reviews of the emergency management plan with employees, specifically failing to review all required topics such as information about explosions.

The investigation was triggered by multiple complaints (KS00170998, KS00170924, KS00170746, KS00170748, KS00170751, KS00170752, KS00170754, KS00170755, KS00170758, and KS00170618). The immediate jeopardy was related to failure to identify Resident 6's code status during an emergency, which was removed after the facility implemented corrective actions.

The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide adequate bathing and personal hygiene for dependent residents, failure to properly identify and confirm a resident's code status during an emergency leading to immediate jeopardy, and failure to safely position a resident in a sling during mechanical lift transfers.

The facility outlines corrective actions to achieve significant compliance with deficiencies related to resident bathing preferences, CPR policies and procedures, advanced directives, hospital transfer packets, and safe resident transfers including lift training following a fall incident.

The visit included complaint investigations KS00146876, KS00162057, KS00163490 related to resident rights, advance directives, transfer and discharge, medication management, and dialysis care.

The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to document advance directives and code status, failure to document required discharge information and provide discharge summaries, failure to notify residents and representatives of hospitalizations and bed-hold policies, failure to complete timely Minimum Data Set (MDS) assessments, failure to document dialysis fistula assessments, and failure to follow physician orders for medication administration and monitoring.

The facility developed and implemented a system to assure correction and continued compliance, including staff education on nail care and weekly monitoring of nail care on residents.

All previously cited deficiencies were corrected as of the revisit date, with each deficiency fully identified by regulation number and marked as completed.

The visit was triggered by complaint investigation #KS00157160. The complaint was substantiated as the facility failed to provide nail care to two residents as required.

The facility failed to provide necessary nail care for two residents (R1 and R4), resulting in poor grooming and hygiene. Observations and interviews confirmed that nail care was not performed as expected despite documented care plans and staff responsibilities.

The inspection was a resurvey with complaint investigations #137211, #141657, #142649, #144747, #144908, #147573, #150095, #150263, #150567, #150621, #150914, #150905, #153176, #153734, #153754, #154836, #155786, #156279, #156395, #156533.

The facility was found deficient in multiple areas including failure to complete functional capacity screening and negotiated service agreements on admission, inadequate provision of health care services including weight monitoring, medication administration errors, failure to notify medical providers of medication regimen variances, incomplete employee records, inadequate documentation of incidents, failure to conduct quarterly emergency preparedness reviews with residents, and ongoing bed bug infestation with insufficient treatment documentation and control measures.

The facility failed to ensure full functionality of the wireless call light system because staff on the 900 hallway did not consistently carry pagers to receive resident call light notifications or escalation notices, resulting in inadequate response to call lights. The facility also lacked a policy on call light response times and pager use.

The Plan of Correction outlines corrective actions to address staffing policies, procedures, and practices, including education of the Administrator and Director of Nursing, implementation of pager procedures, weekly staffing stabilization meetings, installation of call light monitors, and auditing of call light reports to ensure timely response and compliance with state staffing requirements.

The facility failed to ensure nursing staff carried the appropriate pagers to respond adequately to the escalating call light system. Additionally, the facility did not have a functional call light system with visual signals on the 900 and 200 hallways, as wall monitors were nonfunctional and the temporary laptop monitor was inaccessible due to unknown login credentials.

The Plan of Correction outlines corrective actions including staff education on bowel and bladder assessment, comprehensive care plan documentation audits, staffing policy education, installation of call light monitors, and auditing of call light response to ensure compliance with regulations.

The Plan of Correction outlines multiple corrective actions including staff education on resident rights, care plan revision, restorative services, infection control, and blood sugar monitoring policies, with audits scheduled to ensure compliance.

The visit was triggered by complaint investigations #139275 and #141772.

The facility was found deficient in multiple areas including resident rights and dignity, care plan timing and revision, activities of daily living, ADL care for dependent residents, nutrition and hydration status maintenance, drug regimen review and monitoring, frequency of meals/snacks at bedtime, and infection prevention and control.

The citation represents findings from complaint investigation KS00143922. The facility lacked an escalating call light system and did not have enough pagers for all nursing staff, including charge nurses.

The facility failed to have a resident call light system that escalated periodically when staff did not respond within a designated time frame. Observations and interviews confirmed that not all nursing staff carried pagers and the facility lacked an escalating call light system as required.

Deficiencies included lack of guidance for an escalating call light system and inadequate wound care protocols. The facility developed and implemented corrective actions including re-education of licensed nurses and establishment of new policies to ensure compliance.

The inspection was triggered by complaint investigations KS00143168 and KS00142860.

The facility failed to review and revise care plans after resident falls to include appropriate fall prevention strategies based on root cause analysis, failed to provide necessary bathing services to maintain grooming and hygiene for some residents, failed to ensure adequate supervision to prevent falls, failed to check feeding tube placement prior to administering fluids and medications, and failed to develop collaborative hospice care plans including both hospice and facility services.

The plan outlines corrective actions including education for licensed nurses on root cause analysis and fall prevention, updating resident bathing preferences, re-education on PEG tube policies, and improving hospice care plan documentation to ensure compliance with regulations.

All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with completion dates documented for each.

The visit was a resurvey with complaint investigations identified by complaint numbers #106281, #1227678, #126527, and #128060.

The inspection found multiple deficiencies including failure to develop complete negotiated service agreements for residents, lack of nurse identification responsible for health service plans, incomplete self-administration medication assessments, improper labeling of over-the-counter medications, failure to conduct quarterly emergency management plan reviews with staff and residents, and non-compliance with tuberculosis screening guidelines.

The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective January 14, 2018.

The complaint investigation #124122 involved allegations that the facility failed to report and properly investigate potential abuse and misappropriation of resident property. Resident #1 reported inappropriate touching which was not reported to the state agency. Resident #2 reported a missing check which was not reported to the state agency. Both allegations were not thoroughly investigated as required.

The facility failed to report 2 of 3 allegations of potential abuse, neglect, and/or exploitation to the state agency and failed to conduct thorough investigations for these allegations. Specifically, the facility did not report an allegation of potential abuse involving Resident #1 and an allegation of potential misappropriation of money involving Resident #2. Investigations were incomplete and did not include interviews with all relevant parties.

Complaint was investigated immediately on 2017-11-27 and found to be unfounded due to a medical condition. Resident #1 was interviewed again on 2017-12-12 with no complaints. Resident #2 was discharged on 2017-12-14; a misplaced check was reissued on 2017-12-05.

The complaint investigation found the complaint against Resident #1 to be unfounded due to a medical condition that has since been resolved. Issues included a misplaced check for Resident #2 that was not cashed, which was subsequently reissued. The facility implemented corrective actions including staff education on abuse/neglect policies and ongoing resident interviews to monitor compliance.

The report confirms that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of 05/12/2017. No other deficiencies or uncorrected issues are noted.

The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety. Deficiencies were cited at a level of actual harm or above, leading to enforcement remedies including denial of payment for new admissions.

Complaint investigation #114609 focused on accident hazards related to risk of elopement for three residents. The investigation found failures in assessment and intervention implementation that placed residents at risk, including an immediate jeopardy event involving resident #1 exiting the facility unnoticed and falling.

The facility failed to accurately assess residents' risk for elopement and to develop individualized interventions to prevent elopement for three residents. Resident #1 exited the building without staff knowledge, resulting in a fall outside the facility. The facility also failed to properly complete wander guard assessments and implement appropriate interventions for residents #2 and #3, placing them at risk for elopement.

The revisit confirmed that the previously cited deficiencies, specifically those under regulation 483.10(c)(6)(8)(g)(12) and 483.24(a)(3), were corrected as of 04/14/2017.

The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety. Deficiencies were cited that constituted a level of actual harm or above, leading to enforcement remedies including denial of payment for new admissions.

The complaint investigation #113849 found that staff failed to initiate CPR for Resident #1 who was a full code and unresponsive, resulting in the resident's death. The facility's failure to honor the resident's advance directives placed the resident in immediate jeopardy.

The facility failed to initiate CPR for Resident #1 who was a full code and expressed a desire for CPR, resulting in the resident's death. Staff did not follow the resident's advance directives, placing the resident in immediate jeopardy. The facility implemented corrective actions to address the failure.

The survey found isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective January 6, 2017.

The facility was found deficient in multiple areas including failure to timely convey resident funds upon death, failure to honor resident preferences for wake time and bathing, inadequate individualized activity programs, incomplete comprehensive care plans, failure to revise care plans for pressure ulcers, inadequate oral care, inconsistent pressure ulcer monitoring and treatment, unsafe bed rail positioning, insufficient hydration practices, and failure to monitor and report blood sugar irregularities and medication effects.

The Plan of Correction addresses multiple deficiencies related to resident funds management, honoring resident preferences for care and activities, wound care, oral care, bed safety, hydration, medication management, and behavior management. The facility outlines corrective actions including staff education, care plan updates, audits, and ongoing monitoring to ensure compliance.

The report confirms that all previously identified deficiencies have been corrected as of the revisit date.

The visit included complaint investigations #89409 and #100251 as stated in the initial comments.

The facility failed to make the most recent survey report available to residents, staff, and visitors; failed to make the emergency management plan available; and failed to maintain a safe environment related to unlocked chemicals, posing potential risks to residents.

The revisit report indicates that the deficiencies previously cited under regulation numbers 483.10(b)(11) and 483.25 were corrected as of 06/30/2016.

The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance and the plan of correction.

The complaint investigation (#KS00100681) focused on the facility's failure to notify the physician and legal representative of Resident #1's significant change in condition and failure to provide adequate nursing assessments during the resident's decline.

The facility failed to immediately inform the physician and legal guardian/representative of a significant change in medical condition (decreased level of consciousness) for one resident. Additionally, the facility failed to provide timely and thorough nursing assessments, including vital signs monitoring, during the resident's decline, resulting in inadequate care to maintain the resident's highest practicable physical well-being.

This Plan of Correction addresses deficiencies cited during a complaint investigation at LakePoint Retirement on 06/02/2016.

The facility developed and implemented a system to assure correction and continued compliance with regulations, including educating licensed nursing staff on physician notification and nursing assessments related to changes in resident conditions, and performing ongoing audits reviewed by the QA committee.

The survey found the most serious deficiencies to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.

The report confirms that all previously cited deficiencies identified by regulation numbers 483.15(e)(1), 483.25(c), 483.25(l), 483.35(i), and 483.60(c) were corrected as of the revisit date.

The revisit confirmed that the deficiencies identified under regulations 483.10(b)(11) and 483.25 were corrected as of 06/14/2015.

The inspection included complaint investigations #86839, #81765, #85512, #83803, #83737, #82387, and #81723.

The facility was found deficient in multiple areas including failure to ensure residents had accessible call lights, inadequate pressure ulcer prevention and treatment, failure to prevent unnecessary drug use and inadequate monitoring of psychotropic medications, unsanitary food handling practices, and failure of the pharmacist to report medication regimen irregularities.

The plan outlines corrective actions for multiple deficiencies including call light placement, pressure ulcer management, psychotropic medication behavior monitoring, and food safety practices. The facility has implemented audits, staff education, and ongoing monitoring to ensure compliance.

The surveys found the most serious deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted plans of correction and was found to be in substantial compliance based on credible allegation of compliance and the plans of correction.

The surveys found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted plans of correction which were accepted, resulting in a finding of substantial compliance effective June 26, 2015.

Investigation of complaint #KS00084354 found substantiated failures related to physician notification and resident care for Resident #2.

The facility failed to immediately notify the physician when Resident #2 experienced significant changes in medical condition, including low blood pressure readings and brief deterioration in level of consciousness. Additionally, the facility failed to provide timely and thorough nursing assessments and reassessments to maintain the resident's highest practicable physical well-being.

This Plan of Correction is related to a complaint investigation survey conducted on 2015-05-15.

The facility was cited for deficiencies including failure to follow standing orders regarding blood pressure and failure of licensed nurses to follow up and reassess residents in a timely manner. The plan outlines corrective actions including staff education and ongoing nursing documentation review.

The report confirms that the previously cited deficiencies identified by regulation numbers 26-41-201(c), 26-41-202(d), and 26-41-204(d) were corrected as of 10/15/2014.

This Plan of Correction addresses deficiencies cited during a complaint investigation survey at Lake Point Wichita Assisted Living.

The facility had deficiencies related to incomplete or untimely Functional Capacity Screens, Negotiated Service Agreements, and Health Service Plans, particularly concerning residents with significant changes in condition such as wounds or ulcers.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

Investigation of complaint #78547 regarding failure to complete required functional capacity screens and negotiated service agreements following significant changes in resident condition.

The facility failed to complete functional capacity screens and negotiated service agreements within required timeframes for residents with significant changes in condition, specifically related to wound care. The facility also failed to complete a health care service plan including the description of health care services and the responsible licensed nurse for one resident with a wound.

The report confirms that deficiencies identified in prior inspections, specifically those referenced by regulation numbers 28-39-158(c) and 28-39-158, were corrected as of 08/20/2014.

The inspection findings are based on complaint investigations #77231, 77166, and 75440. The complaints were substantiated as evidenced by the cited deficiencies.

The facility failed to serve food at proper temperatures, with hot foods below required temperatures and no monitoring of cold food temperatures. Additionally, the facility failed to maintain sanitary conditions in the kitchen, including inadequate cleaning of equipment, surfaces, and improper sanitization procedures.

This Plan of Correction is related to a complaint survey as indicated by the reference to 'Complaint' in the deficiency report link and the nature of the deficiencies addressed.

Deficiencies involved food temperature control, sanitation and cleaning of kitchen equipment, and proper documentation and training related to these areas. Corrective actions include staff education, calibration of thermometers, removal of salad bar, replacement of oven, and implementation of cleaning and audit schedules.

The revisit confirmed that the previously reported deficiency identified by regulation 28-39-156(f) was corrected as of 03/07/2014.

The report shows that deficiencies identified under regulations 483.25 and 483.60(a),(b) were corrected as of 03/07/2014, indicating compliance with the required corrective actions.

The report confirms that previously identified deficiencies with ID prefixes S1166 and S1172 were corrected as of 03/07/2014.

All previously reported deficiencies identified on the CMS-2567 were corrected as of 03/07/2014, with corrective actions completed for each cited regulation.

The Plan of Correction details multiple deficiencies related to resident care, documentation, medication administration, staff education, and facility procedures. The facility outlines specific corrective actions, education plans, audits, and monitoring to achieve substantial compliance by March 7, 2014.

The facility had multiple deficiencies including failure to provide required liability notices, failure to ensure residents' rights to make choices, failure to maintain sanitary environment, incomplete comprehensive assessments, failure to update care plans, inadequate monitoring of fluid restrictions and dialysis care, insufficient staffing, failure to follow up on PRN medications, and failure to secure medications properly.

The Plan of Correction outlines corrective actions taken to address deficiencies related to bowel movement monitoring, medication documentation, and medication destruction procedures to ensure compliance with regulations.

The investigation was triggered by complaints #71262 and #71909. The facility did not follow proper medication destruction procedures, allowing CMAs to destroy medications alone or with another person, without pharmacist involvement or proper documentation.

The facility failed to ensure that discontinued, outdated, and unused medications were destroyed by a pharmacist and a licensed nurse as required by state regulations. Instead, certified medication aides destroyed medications without proper oversight or documentation, posing potential risk to all residents.

The revisit inspection confirmed that previously reported deficiencies identified by regulation numbers 26-39-103 (b), 26-41-204 (i), and 26-41-205 (l)(1) were corrected as of 11/22/2013.

The complaint investigation involved allegations related to resident rights violations, bathing assistance, and medication regimen monitoring for specific residents.

The facility failed to ensure one resident was free from interference and coercion regarding attending activities, failed to provide bathing as frequently as directed in health service plans for two residents, and failed to adequately monitor and document the administration and effectiveness of PRN and psychotropic medications for two residents.

The plan addresses multiple deficiencies including allowing residents to attend activities despite inappropriate behaviors, bathing assistance and documentation issues, and medication review and management particularly related to PRN and psychotropic medications.

The report confirms that the deficiency identified under regulation 26-40-303 was corrected as of the revisit date, November 14, 2012.

The visit was triggered by complaints #58992 and #59731. The findings substantiated issues with the nursing call system and staff response times.

The facility failed to have a wireless call system that repeated unanswered signals every three minutes and did not ensure that all staff carried pagers as required. Multiple residents reported delays in staff responding to call lights, and staff interviews confirmed inconsistent pager use and lack of guidance on locating residents.

The report shows that all previously cited deficiencies were corrected as of 08/11/2011, with no uncorrected deficiencies noted at the time of this revisit.

The visit included a complaint investigation (#48608) related to multiple issues including restraint use, resident rights, discharge planning, assessment accuracy, care planning, personal hygiene, environmental safety, medication monitoring, food sanitation, and infection control.

The facility was found deficient in multiple areas including failure to properly assess and provide appropriate bedrails, failure to follow resident choices regarding wake times, inadequate discharge planning, incomplete comprehensive assessments, inaccurate assessments, failure to develop and revise comprehensive care plans, inadequate personal hygiene care, unsafe environment hazards, failure to monitor medication effectiveness, failure to maintain sanitary food service conditions, and failure to implement effective infection control practices.

The plan outlines corrective actions addressing deficiencies related to hospice care assessments, catheter care, care plan updates, call system alerts, and related staff education and audits to ensure compliance.

This Plan of Correction is related to a complaint investigation identified as Lakepoint Wichita complaint 05032017.

The facility developed and implemented a system to assure correction and continued compliance, including updated wander assessment tools, staff education, policy revisions, and ongoing audits to prevent elopement incidents.

The facility developed and implemented corrective actions to address deficiencies including posting the survey report, posting the Emergency Management Plan, and ensuring chemicals are stored in a locked environment.

The visit was complaint-related, addressing concerns about honoring advance directives and code status for residents who are full code.

The facility developed and implemented a system to assure correction and continued compliance with regulations, specifically addressing issues related to code status and advance directives following the death of a resident.

The Plan of Correction outlines corrective actions for multiple deficiencies including staff phone use during resident care, code status documentation, discharge documentation, hospitalization notifications, bed hold policy, timely completion of discharge/death MDS, discharge summaries, post-dialysis assessments, and medication oversight.