Inspection Report Summary
The most recent inspection on February 8, 2013, found that previously cited deficiencies had been corrected. Earlier inspections showed several deficiencies related mainly to documentation of Medicare non-coverage notices, individualized care planning, medication storage and labeling, and supervision of residents at risk for elopement. A complaint investigation in June 2012 substantiated a failure to provide adequate supervision for a resident with dementia who left the facility unsupervised, which resulted in immediate jeopardy; the facility responded with staff training and system upgrades. No fines, license suspensions, or other enforcement actions were listed in the available reports. The facility’s record shows improvement over time, with the most recent follow-up confirming correction of prior issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
150 residents
Based on a January 2013 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 3
Date: Feb 8, 2013
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as noted on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously cited deficiencies identified by regulation numbers F0156, F0279, and F0431 were corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 483.10(b)(5) - (10), 483.10(b)(1)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.60(b), (d), (e)
Inspection Report
Re-Inspection
Census: 150
Deficiencies: 3
Date: Jan 15, 2013
Visit Reason
The inspection was a Health Resurvey conducted to assess compliance with regulatory requirements including resident rights, comprehensive care plans, and medication management.
Findings
The facility failed to provide proper Liability Notice and Beneficiary Appeal Rights Review documentation for several residents, failed to develop a comprehensive individualized care plan for activities for one resident, and failed to properly label and store medications on two medication carts.
Deficiencies (3)
Failed to provide Liability Notice and Beneficiary Appeal Rights Review for resident #286 and failed to include reason for discharge on notices for four residents receiving skilled Medicare services.
Failed to develop a comprehensive individualized care plan for activities for 1 of 29 residents sampled.
Failed to date insulin pens upon opening and failed to properly store and label medications on medication carts.
Report Facts
Census: 150
Sample size: 29
Medication carts with issues: 2
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jan 15, 2013
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited during the annual survey completed on January 15, 2013, at Lakeview Village.
Findings
The plan outlines corrective actions for multiple deficiencies including notification procedures for Medicare non-coverage, provision of resident activities, and proper medication storage and labeling. Quality assurance monitoring processes were established to ensure ongoing compliance.
Deficiencies (4)
Deficiencies cited during the annual survey completed on 1/15/13 requiring facility-wide corrective actions.
Failure to provide appropriate notice of Medicare Non-Coverage to residents receiving skilled services.
Failure to provide activities of resident choice when not receiving therapy.
Unmarked insulin pens and medication improperly stored during the survey.
Report Facts
Date of annual survey: Jan 15, 2013
Date of completion for F0000: Jan 18, 2013
Date of completion for F156-D: Jan 18, 2013
Date of completion for F279-D: Feb 8, 2013
Date of completion for F431-D: Feb 1, 2013
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: Jun 7, 2012
Visit Reason
The inspection was conducted as a complaint investigation (#KS56859) regarding the facility's failure to provide adequate supervision for a resident with Alzheimer's dementia who wore a wandering device and left the facility unsupervised for over two hours.
Complaint Details
Complaint investigation #KS56859. The resident with Alzheimer's dementia left the facility unsupervised for over two hours through an alarmed door. Multiple staff failed to respond to alarms promptly, placing the resident in immediate jeopardy.
Findings
The facility failed to provide adequate supervision for a cognitively impaired, independently ambulatory resident at risk for falls and elopement, resulting in the resident leaving the facility through an alarmed door and being missing for over two hours. Multiple staff failed to respond promptly to door alarms and wanderguard alerts. The facility subsequently provided staff training, upgraded the alarm system, and implemented monitoring procedures to prevent recurrence.
Deficiencies (1)
Failed to provide adequate supervision for a resident with a wanderguard who left the facility unsupervised for over two hours, missing even hour checks as care planned.
Report Facts
Resident census: 111
Fall Risk assessment score: 12
Elopement Assessment score: 14
Number of alarm activations: 116
Number of staff trained: 52
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 7, 2012
Visit Reason
This document is a Plan of Correction submitted in response to past noncompliance identified in a prior inspection.
Findings
The plan indicates that no plan of correction was required for the past noncompliance, with compliance training completed on 04/29/2012 and additional training on 05/19/2012.
Deficiencies (2)
Past noncompliance: no plan of correction required.
Past noncompliance: no plan of correction required.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Oct 27, 2011
Visit Reason
This is a post-certification revisit conducted to verify that previously identified deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that all previously cited deficiencies identified by their regulation numbers and ID prefixes were corrected by the revisit date of 10/27/2011.
Deficiencies (5)
Deficiency identified under regulation 483.10(b)(5) - (10), 483.10(b)(1)
Deficiency identified under regulation 483.25(l)
Deficiency identified under regulation 483.35(i)
Deficiency identified under regulation 483.60(a),(b)
Deficiency identified under regulation 483.60(c)
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Census: 142
Deficiencies: 5
Date: Sep 27, 2011
Visit Reason
The inspection was a Health Resurvey to assess compliance with federal regulations related to resident rights, drug regimen, food sanitation, pharmaceutical services, and medication regimen review.
Findings
The facility failed to provide individualized Medicare Non-coverage notices, failed to identify and monitor Black Box Warnings for antipsychotic and other medications for multiple residents, failed to maintain sanitary food storage and preparation conditions, failed to date multi-use medication vials, and failed to ensure the pharmacist reported medication irregularities to the attending physician and director of nursing.
Deficiencies (5)
Failed to provide individualized Notice of Medicare Provider Non-coverage with specific reasons for discharge for 3 residents.
Failed to identify and monitor Black Box Warnings for medications for 3 residents (#157, #328, #42).
Failed to store, prepare, and serve food under sanitary conditions, including undated and uncovered food items and unsanitary kitchen equipment.
Failed to date multi-use medication vials in 1 of 4 medication rooms.
Pharmacist failed to report medication irregularities related to Black Box Warnings to attending physician and director of nursing.
Report Facts
Residents sampled: 16
Residents with Medicare Non-coverage notice issues: 3
Residents reviewed for unnecessary drugs: 10
Undated opened multi-use medication vials: 3
Opened undated ice cream cartons: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff B | Acknowledged giving standard non-coverage letters without individualization. | |
| Administrative staff A | Acknowledged non-coverage form was standard and not individualized. | |
| Licensed staff C | Confirmed facility does not monitor Black Box warnings and called Pharmacy Consultant about missing warnings. | |
| Administrative staff C | Revealed kitchen staff cleaning schedule and labeling requirements. | |
| Administrative staff D | Confirmed improper thawing of pork roast directly in sink. | |
| Administrative staff E | Observed touching food and surfaces with same gloves without hand washing. | |
| Licensed staff B | Acknowledged multi-use medication vials lacked open dates. | |
| Licensed staff A | Stated expectation to date multi-use vials and discard after 30 days. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 7, 2010
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by ASPEN Event ID IJLY11 and State ID N046007.
Findings
No specific deficiencies or findings are detailed in this document; it serves as a placeholder or record for the Plan of Correction with no records found.
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