Inspection Reports for Lakepoint Augusta LLC
901 LAKEPOINT DRIVE, AUGUSTA, KS, 67010
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 8, 2019, found no deficiencies and confirmed the facility was in compliance with all regulations. Prior inspections showed a pattern of deficiencies primarily related to resident care, including pressure ulcer treatment, medication administration errors, and failure to follow individualized care plans, as well as infection control and safety measures. Several complaint investigations were substantiated, involving issues such as inadequate pressure ulcer care, medication errors, and failure to prevent resident access to hazardous items despite care plans. Enforcement actions were imposed in 2016 and 2017 due to deficiencies related to pressure ulcers and immediate jeopardy from inadequate supervision, including denial of payment for new admissions, but these were resolved in subsequent inspections. The facility’s recent clean inspection suggests improvement following earlier citations and enforcement actions.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
23.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
290% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
79 residents
Based on a September 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 8, 2019
Visit Reason
An offsite revisit was conducted on 11/08/19 to verify correction of all previous deficiencies cited on 09/10/19.
Findings
All deficiencies have been corrected as of the compliance date of 10/25/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 8, 2019
Visit Reason
An offsite revisit was conducted on 11/08/19 to verify correction of all previous deficiencies cited on 09/10/19.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 10/25/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Compliance date: Oct 25, 2019
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 2
Date: Sep 10, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #144546 and 144836 to assess compliance with care standards and infection control.
Complaint Details
The visit was complaint-related, involving investigations #144546 and 144836. The facility was found deficient in pressure ulcer care and infection control practices.
Findings
The facility failed to provide necessary pressure ulcer care for one resident, including failure to reposition the resident for over three hours and 23 minutes and failure to apply physician-ordered dressing. Additionally, the facility failed to establish an antibiotic stewardship program with proper monitoring of antibiotic use.
Deficiencies (2)
Failure to provide necessary pressure ulcer care, including repositioning and dressing application for Resident 77.
Failure to establish an infection prevention and control program including an antibiotic stewardship program with monitoring of antibiotic use.
Report Facts
Resident census: 79
Residents sampled: 20
Residents reviewed for pressure ulcer: 3
Duration resident not repositioned: 203
Pressure ulcer measurements: 0.9
Pressure ulcer measurements: 1
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 1.6
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0
Pressure ulcer measurement: 0.5
Pressure ulcer measurement: 0.2
Pressure ulcer measurement: 0.1
Prostat supplement dosage: 30
UTI cases documented November 2018: 8
UTI cases cultured November 2018: 5
UTI cases documented January 2019: 8
UTI cases cultured January 2019: 4
UTI cases documented March 2019: 11
UTI cases cultured March 2019: 5
UTI cases documented April 2019: 11
UTI cases cultured April 2019: 5
UTI cases documented May 2019: 8
UTI cases cultured May 2019: 5
UTI cases documented June 2019: 3
UTI cases documented July 2019: 4
UTI cases cultured July 2019: 3
UTI cases documented August 2019: 9
UTI cases cultured August 2019: 5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 9, 2019
Visit Reason
An offsite revisit was conducted on 08/09/19 to verify correction of all previous deficiencies cited on 07/02/19.
Findings
All deficiencies have been corrected as of the compliance date of 07/09/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 2, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The facility has developed and implemented a facility-wide system to assure correction and continued compliance with regulations. Education and ongoing monitoring by the Interdisciplinary Team and nursing staff are planned to ensure adherence to care plans and medication administration policies.
Deficiencies (2)
Failure to ensure resident care plans were followed and updated appropriately.
Failure to ensure medication aides were following policy and procedures during medication administration.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Jul 2, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#142825) regarding medication administration errors at the facility.
Complaint Details
Complaint investigation #142825 focused on medication errors where staff administered medications to the wrong resident. The error was substantiated by observation, interviews, and record review.
Findings
The facility failed to ensure that one resident received medications as ordered by the physician when staff administered medications intended for another resident. The medication error was reported immediately by staff, and the resident remained alert and oriented after the incident.
Deficiencies (2)
Facility failed to ensure that one resident received medications as ordered by the physician when staff administered medications to the wrong resident.
Facility failed to ensure residents were free of significant medication errors when staff administered medications to the wrong resident.
Report Facts
Census: 87
Residents sampled: 3
Medication error incidents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Direct Care Staff / Medication Aide | Administered wrong medications to resident and reported the error. |
| Staff B | Licensed Nursing Staff | Interviewed regarding medication error and resident's condition. |
| Staff A | Administrative Nursing Staff | Provided expectations for medication error reporting and correction. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 25, 2019
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-05-29.
Findings
All deficiencies have been corrected as of the compliance date of 2019-06-07, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Date: May 29, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about the facility's treatment and services for residents with mental and psychosocial issues, specifically regarding the care of a resident with suicidal ideation.
Complaint Details
The complaint investigation numbers were 140849 and 140513. The resident was found with a trash bag over their head and a drawstring around their neck, indicating a suicide attempt. The facility failed to follow the care plan to prevent access to plastic bags. The resident was later stabilized and not at risk for further harm.
Findings
The facility failed to provide planned interventions to ensure the safety of a resident with a history of suicidal ideation, who was found with a trash bag over their head and a drawstring wrapped around their neck. Despite care plans to prevent access to plastic bags, the resident had access to them, indicating a failure to follow the plan of care.
Deficiencies (1)
Failure to provide planned interventions for a resident with behaviors to ensure safety, specifically not preventing access to plastic bags despite a history of suicidal ideation.
Report Facts
Resident census: 83
Residents reviewed for behaviors: 3
Resident BIMS score: 9
Resident cognition score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Received phone call from resident's relative and checked on resident | |
| Licensed Nurse D | Visited resident's room and observed resident lying in bed | |
| Social Worker E | Found resident with trash bag over head and drawstring around neck, verified incident, and reported findings | |
| Housekeeping Supervisor F | Reported staff retraining regarding use of plastic bags in resident's room | |
| Administrative Staff A | Reported knowledge of trash can liner presence and resident's stable condition |
Inspection Report
Follow-Up
Deficiencies: 9
Date: Dec 27, 2018
Visit Reason
This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were completed.
Findings
All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with completion dates noted for each.
Deficiencies (9)
Deficiency related to regulation 26-41-201 (d)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-202 (j)
Deficiency related to regulation 26-41-204 (a)
Deficiency related to regulation 26-41-204 (i)
Deficiency related to regulation 26-41-206 (e) (1)
Deficiency related to regulation 28-39-254
Deficiency related to regulation 28-39-255
Deficiency related to regulation 28-39-255
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 10/23/2018.
Findings
All deficiencies have been corrected as of the compliance date of 11/22/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 9
Date: Nov 27, 2018
Visit Reason
The inspection was a resurvey with investigation of complaint #127070 at an assisted living facility conducted over multiple days in November 2018.
Complaint Details
The inspection was conducted as a resurvey with investigation of complaint #127070.
Findings
The facility was found deficient in multiple areas including inaccurate functional capacity screening, incomplete negotiated service agreements, failure to monitor outside service providers, inadequate provision of health care services, unsafe food storage, unlocked storage of hygiene supplies accessible to cognitively impaired residents, unlocked laundry room with chemicals not secured, and unsanitary dietary areas.
Deficiencies (9)
Failure to ensure resident's functional capacity screening accurately reflected resident's abilities, specifically medication management.
Failure to develop written negotiated service agreements that included descriptions of services, identification of providers, and payment responsibilities.
Failure to monitor services provided by outside resources and act as an advocate when services did not meet professional standards.
Failure to ensure licensed nurse provided or coordinated necessary health care services in accordance with functional capacity screening and negotiated service agreement.
Failure to provide health care services of skin assessments and daily weight monitoring by a licensed nurse in accordance with acceptable standards of practice.
Failure to store food under safe and sanitary conditions; food items were stored without dates, improperly sealed, or partially uncovered.
Failure to maintain facility to protect health and safety of residents; unlocked bathing/storage room accessible to cognitively impaired residents with shared hygiene items.
Failure to store chemicals in a locked cabinet in the laundry room.
Failure to ensure dietary area provided sanitary meal service; floor drain covered with stained adhesive flooring and plate dispenser stored over floor drain.
Report Facts
Residents sampled: 3
Census: 32
Dates of inspection: 5
Fall risk assessment score: 16
Weight gain threshold: 3
Weight gain threshold: 5
Date of food items: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse B | Operator/Licensed Nurse | Named in multiple findings including inaccurate functional capacity screening, failure to develop negotiated service agreements, failure to monitor outside services, and failure to ensure health care services. |
| Licensed nurse C | Licensed Nurse | Involved in interviews and record reviews related to monitoring services and health care provision. |
| Dietary manager D | Dietary Manager | Removed improperly stored food items from kitchen drawer. |
| Dietary employee F | Dietary Employee | Interviewed about plate dispenser and kitchen sanitation. |
| Certified staff E | Certified Staff | Provided information about resident care and fall risk interventions. |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Nov 22, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.
Findings
The facility developed and implemented corrective actions including staff in-service training, random checks by management, replacement and repair of furniture and equipment, and ongoing monitoring by the Quality Assurance Performance Improvement Committee to ensure compliance with regulations.
Deficiencies (5)
Housekeeping staff to follow proper cleaning procedures including terminal cleaning and proper chemical usage; furniture and bathroom maintenance issues addressed.
MDS Coordinators educated on responsibilities and assessment completion; Director of Nursing to monitor assessments.
Education on Comprehensive Care Plan Policy and Urinary Incontinence Clinical Protocol; monitoring of bowel and bladder assessments and care plans.
In-service for nursing staff on cleaning and storing nebulizers; monitoring by Director of Nursing.
Maintenance/housekeeping manager educated on garbage and refuse disposal; communication with city for additional receptacles; monitoring of waste disposal.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 6
Date: Oct 23, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation #130532 and #134551 to assess compliance with regulatory requirements.
Complaint Details
The inspection included complaint investigations #130532 and #134551.
Findings
The facility was found deficient in maintaining a safe, clean, and comfortable environment, completing significant change assessments, revising care plans, providing individualized toileting programs, respiratory care, and proper garbage disposal. Multiple deficiencies were noted including unsanitary conditions, failure to complete required assessments and care plan revisions, inadequate respiratory equipment handling, and improper refuse disposal.
Deficiencies (6)
Failed to provide housekeeping and maintenance services to maintain an orderly, sanitary and comfortable environment on 5 of 6 hallways.
Failed to complete significant change MDS assessments for residents #29, #79, and #81 after changes in condition affecting activities of daily living.
Failed to review and revise care plans to include individualized toileting plans for residents #243 and #144.
Failed to provide individualized toileting programs to promote urinary continence for residents #243 and #144.
Failed to provide respiratory care consistent with professional standards by leaving nebulizer machine and tubing on the floor for 3 consecutive days for resident #61.
Failed to dispose of garbage and refuse properly; dumpsters were overflowing and lids could not close on 2 consecutive days.
Report Facts
Census: 92
Residents sampled: 24
Dumpsters observed: 4
Days nebulizer left on floor: 3
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Oct 23, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be a 'F' level deficiency, widespread, constituting no actual harm but 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 11/22/2018.
Deficiencies (1)
Most serious deficiencies found to be a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact person regarding the inspection findings and enforcement. |
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Aug 22, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The facility developed and implemented corrective actions addressing multiple deficiencies including pacemaker monitoring, care plan revisions, Foley catheter care, respiratory distress monitoring, and timely response to call lights.
Deficiencies (6)
All residents with pacemakers have been identified and added to a pacemaker list, with care plans updated accordingly.
MDS coordinators trained on reviewing and revising resident care plans in a timely manner.
Pacemaker monitoring and care plans corrected and staff educated.
Direct care staff educated on Foley catheter care policy including use of securing anchor and maintaining tubing.
Licensed nurses educated on signs and symptoms of respiratory distress and oxygen monitoring policy.
Nursing staff educated on answering call lights timely; call light monitors installed to assist.
Report Facts
Months for monitoring corrective actions: 3
Number of residents randomly monitored monthly: 5
Number of Foley catheters monitored bi-weekly: 2
Number of residents monitored weekly for oxygen saturation: 3
Number of alert and oriented residents met weekly: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Alejandronieto | LNHA | Submitted the Plan of Correction |
| Diana Melander | Added Plan of Correction | |
| Caryl Gill | Modified Plan of Correction |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 6
Date: Aug 22, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers 132473, 131671, 132572, and 132580.
Complaint Details
The inspection was triggered by complaint investigations #132473, 131671, 132572, and 132580.
Findings
The facility failed to develop and implement comprehensive care plans for residents, including failure to monitor pacemakers and oxygen administration. There were deficiencies in care plan timing and revision, quality of care related to pacemaker monitoring, catheter care, oxygen saturation monitoring, and sufficient nursing staff to meet residents' needs in a timely manner.
Deficiencies (6)
Failure to develop and implement a comprehensive care plan for residents related to pacemaker monitoring and oxygen administration.
Failure to develop and revise care plans timely, including lack of interventions for catheter care and fall prevention.
Failure to ensure quality of care by lacking a system to monitor pacemakers timely for multiple residents.
Failure to provide appropriate catheter care including securing catheter and preventing tubing from resting on the floor.
Failure to monitor oxygen saturation levels adequately for residents requiring oxygen therapy.
Failure to provide sufficient nursing staff to meet residents' needs and timely respond to call lights.
Report Facts
Residents selected for sample review: 14
Call light response time: 37
Call light response time: 21
Call light response time: 24
Call light response time: 30
BIMS score: 8
Oxygen saturation: 89
Resident census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Licensed Nursing Staff | Reported on pacemaker monitoring and catheter care practices. |
| Staff E | Licensed Nursing Staff | Reported on pacemaker monitoring and fall interventions. |
| Staff B | Administrative Nursing Staff | Reported on pacemaker monitoring system and oxygen monitoring. |
| Staff Q | Direct Care Staff | Reported on catheter care and securing catheter. |
| Staff R | Licensed Nursing Staff | Performed catheter care and adjusted drainage bag. |
| Staff Y | Direct Care Staff | Assisted resident with oxygen and reported lack of oxygen saturation monitoring. |
| Staff J | Direct Care Staff | Reported on oxygen saturation monitoring practices. |
| Staff L | Direct Care Staff | Reported on resident oxygen use and mobility. |
| Staff Z | Staff Member | Responded to resident call light after delay. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 22, 2018
Visit Reason
An off-site survey was conducted to address deficiencies cited on August 22, 2018.
Findings
The deficiencies cited during the survey were corrected as of the compliance date of September 21, 2018.
Report Facts
Compliance date: Sep 21, 2018
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 22, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a 'F' level deficiency indicating no actual harm but 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 September 21, 2018.
Deficiencies (1)
Most serious deficiency was a 'F' level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact person and signatory related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 30, 2018
Visit Reason
A desk review was conducted for the deficiencies cited on May 31, 2018.
Findings
The deficiencies cited on May 31, 2018 were corrected as of the compliance date of June 30, 2018.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 4
Date: May 31, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigations #129899, #120621, #121065, and #121402.
Complaint Details
The inspection was triggered by complaint investigations #129899, #120621, #121065, and #121402.
Findings
The facility failed to review and revise residents' care plans to instruct staff in individualized care needs, failed to provide adequate assistance with hygiene and bathing, failed to ensure residents received appropriate supervision and assistive devices to prevent accidents, and failed to develop individualized toileting plans to promote continence and prevent urinary tract infections.
Deficiencies (4)
Failure to review and revise residents' care plans to instruct staff in individualized care needs related to falls and urinary incontinence.
Failure to ensure adequate assistance with hygiene including oral care, nail and hair hygiene, and bathing for dependent residents.
Failure to ensure resident received adequate supervision and assistive devices to prevent accidents, including failure to add fall prevention interventions to care plan.
Failure to develop individualized toileting plans to promote continence and provide appropriate perineal care to prevent urinary tract infections.
Report Facts
Residents sampled: 7
Fall risk score: 25
Bathing days missed: 9
BIMS scores: 5
BIMS scores: 6
BIMS scores: 14
BIMS scores: 13
BIMS scores: 8
BIMS scores: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Direct Care Staff | Reported resident #6's toileting needs and fall prevention interventions. |
| Staff H | Direct Care Staff | Reported resident #6 should not be left unattended in recliner and toileting cues. |
| Staff G | Direct Care Staff | Reported bathing and oral care expectations for residents. |
| Staff B | Administrative Nursing Staff | Verified lack of voiding diary and toileting plans; reported bathing and oral care expectations. |
| Staff P | Direct Care Staff | Assisted resident #4 with toileting and dressing. |
| Staff Q | Direct Care Staff | Assisted resident #4 with toileting. |
| Staff R | Direct Care Staff | Assisted resident #4 with toileting. |
| Staff S | Direct Care Staff | Reported resident #5's oral care and transfer needs. |
| Staff T | Direct Care Staff | Reported resident #5's oral care and transfer needs. |
| Staff I | Direct Care Staff | Assisted resident #1 with hygiene and bed mobility. |
| Staff J | Direct Care Staff | Assisted resident #1 with hygiene and bed mobility. |
| Staff K | Direct Care Staff | Reported resident #1's hygiene and toileting needs. |
| Staff M | Activity Staff | Directed resident #2 to room but failed to offer toileting. |
| Staff N | Direct Care Staff | Planned to take resident #2 to dining room without providing other cares. |
| Staff O | Direct Care Staff | Assisted resident #1 with toileting. |
| Staff D | Licensed Nursing Staff | Assisted resident #6 to wheelchair and bed after fall. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: May 31, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The facility developed and implemented a facility-wide system to assure correction and continued compliance with regulations, including staff education on fall interventions, urinary incontinence protocols, oral health care, bathing, and perineal care policies. The Director of Nursing or designee will monitor compliance and review results quarterly with the Quality Assurance Performance Improvement Committee.
Deficiencies (4)
Failure to provide appropriate interventions identifying causal factors of resident falls and proper care planning.
Failure to ensure direct care staff are educated and competent in oral health care, bathing, and perineal care policies.
Failure to provide appropriate interventions identifying causal factors of resident falls and proper care planning.
Failure to re-educate licensed nursing staff on urinary incontinence clinical protocol and ensure proper assessments and care planning.
Report Facts
Complete Date: Jun 30, 2018
Complete Date: Jun 29, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alejandronieto | LNHA | Submitted the Plan of Correction to KDADS |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 31, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an "E" level deficiency indicating no actual harm but 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 June 30, 2018.
Deficiencies (1)
An "E" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Aug 3, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies related to various regulatory requirements were corrected as of 07/12/2017, with no uncorrected deficiencies noted at the time of this revisit.
Deficiencies (7)
Deficiency related to regulation 483.20(b)(1)
Deficiency related to regulation 483.25(d)(1)(2)(n)(1)-(3)
Deficiency related to regulation 483.35(g)(1)-(4)
Deficiency related to regulation 483.60(i)(1)-(3)
Deficiency related to regulation 483.80(a)(1)(2)(4)(e)(f)
Deficiency related to regulation 483.90(i)(5)
Deficiency related to regulation 483.70(d)(1)(2)
Report Facts
Date of revisit: Aug 3, 2017
Date corrections completed: Jul 12, 2017
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 12, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The report shows that the deficiencies previously cited under regulation numbers 28-39-158(g) and 26-40-304 (c)(1)(a)(b)(c) were corrected as of the revisit date 07/12/2017.
Deficiencies (2)
Deficiency related to regulation 28-39-158(g)
Deficiency related to regulation 26-40-304 (c)(1)(a)(b)(c)
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Jun 21, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 06/21/2017.
Findings
The facility has developed and implemented a facility-wide system to assure correction and continued compliance with regulations. Specific corrective actions include staff education, policy reviews, implementation of new forms, and ongoing monitoring by the Director of Nursing and Quality Assurance Performance Improvement Committee.
Deficiencies (7)
Failure to complete assessments accurately and timely by MDS coordinators.
Inadequate safety plan related to elopement policy and drills.
Improper documentation on Daily Nurse Staffing Forms.
Noncompliance with kitchen sanitation and safety policy.
Improper cleaning procedures of glucometers and nebulizers and resident rooms.
Noncompliance with kitchen sanitation and safety policy (re-education and cleaning list implementation).
Policy and procedures availability and review by governing body and medical director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Alejandro Nieto | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 21, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, including re-education of dietary staff on kitchen sanitation and safety, discarding compromised equipment, repairing flooring, and implementing revised cleaning lists with ongoing audits and reviews.
Deficiencies (2)
Dietary Manager and Dietary staff have been re-educated on Kitchen Sanitation and Safety Policy; compromised equipment discarded; monthly audits on cooking utensils implemented.
Compromised flooring in kitchen repaired; wall by kitchen entrance cleaned; revised cleaning list implemented; professional carpet cleaning scheduled; staff in-service on spill cleanup and reporting.
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 7
Date: Jun 21, 2017
Visit Reason
The inspection was conducted as a Health Resurvey, Extended Health Resurvey, and Complaint Investigation #114552 and 116508.
Complaint Details
The visit included complaint investigations #114552 and 116508. Immediate jeopardy was identified related to inadequate supervision leading to resident elopement. The facility abated the immediate jeopardy on 6/15/17 by revising policies and re-educating staff on elopement response.
Findings
The facility was found deficient in completing comprehensive assessments, ensuring resident safety from elopement, posting nurse staffing information, maintaining sanitary food preparation and storage, infection control practices, environmental cleanliness, and governance policies.
Deficiencies (7)
Failed to complete cognition and mood sections for comprehensive assessment of one resident.
Failed to provide adequate supervision to prevent a cognitively impaired resident from wandering away from the facility, placing the resident in immediate jeopardy.
Failed to post daily nurse staffing sheets including total number and actual hours worked for licensed nursing and direct care staff.
Failed to store and prepare food under sanitary conditions; issues included compromised cutting boards, dirty utensils, dusty storage lids, and unclean equipment.
Failed to properly clean shared glucometer and nebulizer equipment, and failed to properly clean resident bathrooms and laundry equipment, risking infection spread.
Failed to maintain cleanliness of floors in kitchen, walk-in refrigerator, and walk-in freezer.
Failed to have a functioning governing body that reviewed all facility policies and procedures on an annual basis.
Report Facts
Resident census: 74
Residents sampled: 18
Residents requiring glucose testing: 13
Residents requiring nebulizer treatments: 7
Resident elopement risk score: 7
Resident elopement risk score: 1
Resident BIMS score: 8
Resident BIMS score: 15
Resident mood score: 0
Time resident was outside after elopement: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Direct Care Staff | Named in infection control deficiency related to improper cleaning of nebulizer equipment. |
| Staff E | Direct Care Staff | Named in infection control deficiency related to improper cleaning of glucometer. |
| Staff I | Housekeeping Staff | Named in infection control deficiency related to improper cleaning of resident bathrooms. |
| Administrative Staff B | Administrative Nursing Staff | Named in multiple findings including elopement response, infection control, and nurse staffing posting. |
| Administrative Staff A | Administrator | Named in deficiency related to lack of functioning governing body and policy access. |
| Staff M | Direct Care Staff | Named in resident elopement incident and search. |
| Staff N | Direct Care Staff | Named in resident elopement incident and search. |
| Staff P | Licensed Nursing Staff | Named in resident assessment and elopement risk findings. |
| Staff J | Direct Care Staff | Named in resident assessment findings. |
| Staff L | Licensed Nursing Staff | Named in resident elopement incident and search. |
| Staff T | Dietary Staff | Named in kitchen sanitation findings. |
| Staff F | Direct Care Staff | Named in glucometer cleaning deficiency. |
| Staff G | Maintenance Staff | Named in bathroom cleaning chemical wet time deficiency. |
| Administrative Staff R | Administrative Dietary Staff | Named in kitchen sanitation findings. |
Inspection Report
Enforcement
Deficiencies: 1
Date: Jun 21, 2017
Visit Reason
The inspection was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs. The survey found the facility was not in substantial compliance and constituted immediate jeopardy to resident health or safety.
Findings
The facility was found to be out of substantial compliance with participation requirements, with deficiencies constituting immediate jeopardy from May 26, 2017 through June 15, 2017. Due to the severity and history of noncompliance, enforcement remedies including denial of payment for new admissions were imposed.
Deficiencies (1)
Noncompliance with F323"J", CFR 01-483.25(h) constituting immediate jeopardy to resident health or safety
Report Facts
Denial of payment effective date: Jul 12, 2017
Provider agreement termination date: Dec 21, 2017
Previous survey date: Aug 16, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Signed letter regarding enforcement action |
| Alejandro Nieto | Administrator | Facility administrator named in report |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 3
Date: Jun 19, 2017
Visit Reason
The inspection was a licensure resurvey to assess compliance with sanitary conditions and maintenance standards in the facility's kitchen and common areas.
Findings
The facility failed to maintain sanitary food preparation conditions, with multiple areas of grime and dirt accumulation in kitchen equipment and surfaces. Additionally, the flooring and carpet in the kitchen and common areas were stained, cracked, or damaged, indicating poor maintenance and cleanliness.
Deficiencies (3)
Accumulation of grime on stove control knobs, oven doors, metal cart, warming tray, microwave interior, cutting boards, spatulas, flour and sugar bins, silverware cart, drawers beneath juice dispenser, potholder drawer, and hand washing sink with discolorations and cobwebs near kitchen door.
Kitchen flooring had discolorations, grime accumulation, cracks, torn areas with tape, and stained walls near kitchen entrance.
Carpet in common areas including near movie theater, dining areas, and front entry door contained multiple stained and discolored areas requiring refurbishing or replacement.
Report Facts
Resident census: 31
Number of stained/discolored carpet areas: 10
Size of carpet stains: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| dietary staff R | Interviewed and confirmed sanitation and maintenance issues in kitchen | |
| administrative nursing staff S | Interviewed and confirmed carpet stains and need for refurbishing | |
| administrative staff A | Interviewed and reported unsuccessful attempts to clean carpet stains |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Oct 11, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report confirms that all previously cited deficiencies identified by regulation numbers 483.20(g)-(j), 483.20(d)(3), 483.10(k), 483.25(c), and 483.25(h) were corrected as of 09/15/2016.
Deficiencies (4)
Deficiency related to regulation 483.20(g)-(j)
Deficiency related to regulation 483.20(d)(3), 483.10(k)
Deficiency related to regulation 483.25(c)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Aug 16, 2016
Visit Reason
This document is a Plan of Correction submitted by LakePoint Augusta in response to deficiencies cited during a prior survey.
Findings
The facility identified multiple deficiencies related to MDS coordination, care plan accuracy, pressure ulcer prevention, and resident environment safety. Corrective actions include staff training, policy reviews, audits, and disciplinary measures.
Deficiencies (4)
Failure to follow MDS manual requirements and responsibilities
Inaccurate or incomplete resident care plans
Inadequate monitoring and prevention of pressure ulcers
Failure to ensure a safe resident environment and adequate supervision to prevent accidents
Report Facts
Plan of Correction completion date: Sep 15, 2016
In-service training dates: Aug 24, 2016
In-service training dates: Sep 2, 2016
In-service training dates: Sep 8, 2016
Care plan audits: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Traci Hayden | Administrator | Submitted the Plan of Correction |
Inspection Report
Routine
Census: 85
Deficiencies: 4
Date: Aug 16, 2016
Visit Reason
The inspection was a Minimum Data Set (MDS) Focus Survey to assess compliance with federal regulations related to resident assessments, care planning, pressure ulcer prevention and treatment, and safe resident transfers.
Findings
The facility failed to accurately code residents' status on MDS assessments, revise care plans with current pressure ulcer treatments, implement effective pressure ulcer prevention and treatment measures, and ensure safe resident transfers using gait belts as care planned. Resident #8 had two unstageable pressure ulcers that were not properly managed, and staff failed to use gait belts during transfers despite care plan instructions.
Deficiencies (4)
Failed to accurately code 2 of 12 residents' status on the MDS assessment related to pressure ulcers and assistance with eating.
Failed to revise 1 of 12 resident's care plan with current pressure ulcer treatment and preventive measures.
Failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores and that a resident with pressure sores receives necessary treatment and services to promote healing.
Failed to ensure staff transferred 1 of 12 residents safely using a gait belt as care planned to prevent potential accidents.
Report Facts
Resident census: 85
Residents sampled for review: 12
Pressure ulcer measurements: 2.6
Pressure ulcer measurements: 2.1
Braden Scale score: 15
Fall risk score: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Administrative Nurse | Verified resident #8's pressure ulcer status, care plan deficiencies, and transfer instructions |
| Staff M | Licensed Nursing Staff | Reported resident #11's transfer and eating status and reviewed MDS coding |
| Staff G | Direct Care Staff | Observed transferring resident #8 without gait belt |
| Consultant F | Dietary Consultant | Reviewed resident #8's nutritional status and wound healing |
| Consultant L | Wound Care Consultant | Provided wound care consultation for resident #8 |
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 16, 2016
Visit Reason
An MDS survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Complaint Details
This enforcement action is based on deficiencies found on the current survey and a complaint survey conducted on December 15, 2015.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, specifically related to pressure ulcers (F314). Due to the facility's history of noncompliance, enforcement remedies including denial of payment for new Medicare and Medicaid admissions were imposed.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers
Report Facts
Denial of payment effective date: Sep 5, 2016
Noncompliance recommendation deadline: Feb 16, 2017
Civil Money Penalty minimum amount: 5000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the matter |
| Lisa Hauptman | CMS Regional Office | Contact person for questions regarding the matter |
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 16, 2016
Visit Reason
An MDS survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs. The survey was triggered by prior noncompliance and resulted in enforcement actions.
Complaint Details
This enforcement action is based on deficiencies found in the current survey and a complaint survey conducted on December 15, 2015.
Findings
The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, specifically related to pressure ulcers (F314). Due to the facility's history of noncompliance, no opportunity to correct deficiencies was given before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers
Report Facts
Denial of payment effective date: Sep 5, 2016
Noncompliance recommendation deadline: Feb 16, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the enforcement action |
| Lisa Hauptman | CMS Regional Office Contact | Contact person for questions regarding the enforcement action |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 6, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that all cited deficiencies identified by regulation numbers 483.20(d)(3), 483.10(k)(2), 483.25(d), and 483.25(l) were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jul 7, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during the Lakepoint complaint inspection conducted on 07/07/2016.
Complaint Details
Plan of Correction is in response to deficiencies cited from the Lakepoint complaint inspection dated 07/07/2016.
Findings
The facility developed and implemented a facility-wide system to assure correction and continued compliance with regulations. Specific corrective actions include mandatory in-services for licensed staff on care plans, bladder assessments, and professional standards of care, along with ongoing audits and reviews by the Director of Nursing or designee.
Deficiencies (4)
Facility-wide system to assure correction and continued compliance within regulations.
Care plans will be reviewed and revised as necessary; mandatory in-service for licensed staff on accurate completion of care plans.
Completion of 3-day bladder diary and new bladder assessment; mandatory in-service for direct care staff on bladder assessments and plans of care.
Ensuring policies and procedures are followed; mandatory in-service for licensed nurses on standards of care including physician orders, medication administration, and bowel movement monitoring.
Report Facts
Complete Date: Aug 6, 2016
Audit Frequency: 5
Audit Frequency: 2
Review Frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Sandra Preston | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 3
Date: Jul 7, 2016
Visit Reason
The inspection was conducted as a complaint investigation, #102037, focusing on care plan revisions, urinary incontinence management, and medication regimen appropriateness.
Complaint Details
Complaint investigation #102037 focused on care plan revisions, urinary incontinence, and medication management issues.
Findings
The facility failed to review and revise care plans for residents to include swallow precautions and individualized toileting plans, failed to ensure residents remained as free from urinary incontinence as possible, and failed to monitor bowel movements adequately for residents receiving stool softeners and laxatives.
Deficiencies (3)
Failed to review and revise the plan of care for 2 of 6 residents to include swallow precautions and individualized toileting plans.
Failed to ensure residents remained as free of urinary incontinence as possible by not developing and implementing individualized toileting plans.
Failed to ensure one resident remained free of unnecessary medications related to failure to monitor bowel movements for administration of stool softeners and laxatives.
Report Facts
Census: 84
Residents reviewed: 6
Days without bowel movement: 7
Days without bowel movement: 5
Days without bowel movement: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff J | Reported facility provided diets as ordered and confirmed resident received physician ordered diet at time of choking incident | |
| Direct Care Staff K | Reported feeding resident and was unaware of special swallow precautions | |
| Administrative Nursing Staff D | Verified care plan lacked swallow precautions and explained bowel movement monitoring process | |
| Administrative Nursing Staff B | Verified care plan lacked swallow precautions and believed resident toileting program was individualized | |
| Direct Care Staff E | Reported resident toileting schedule and assisted resident during toileting observations | |
| Direct Care Staff F | Reported resident toileting assistance and continence status | |
| Direct Care Staff I | Reported resident was not offered toileting prior to supper | |
| Licensed Nursing Staff H | Assisted resident with toileting and reported resident refused to toilet before lunch | |
| Direct Care Staff L | Described daily 'NO BM' report and follow-up process for PRN laxatives |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 7, 2016
Visit Reason
An Abbreviated Survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
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 submitted plan.
Deficiencies (1)
Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 27, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 2016-01-13. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency with ID Prefix F0323 related to regulation 483.25(h)
Report Facts
Deficiency correction date: Jan 13, 2016
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 15, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint survey conducted at Lakepoint Augusta.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint survey at Lakepoint Augusta.
Findings
The facility identified issues related to resident safety during sit-to-stand transfers and has implemented a facility-wide system to assure correction and continued compliance, including staff training, therapy evaluations, and ongoing audits.
Deficiencies (1)
Failure to ensure resident environment free of accident hazards and inadequate supervision/assistance during transfers.
Report Facts
Complete Date for Correction: Jan 13, 2016
Audit Frequency: 5
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Date: Dec 15, 2015
Visit Reason
Complaint investigation #94214 regarding failure to provide adequate supervision and safety devices during transfers using the sit to stand mechanical lift, resulting in a resident fall and injury.
Complaint Details
Complaint investigation #94214 focused on inadequate supervision and failure to use safety straps during mechanical lift transfers, leading to a resident fall and injury. Staff reported residents refusing straps but did not notify nurses. Training was provided but not consistently followed.
Findings
The facility failed to apply safety straps on the sit to stand lift for 4 sampled residents at risk for falls, resulting in one resident falling from the lift and fracturing both hips. Staff inconsistently used safety straps despite training and facility policies requiring their use. Several staff admitted to not using straps if residents refused or did not want them, and refusals were not consistently reported to nursing staff.
Deficiencies (2)
Failure to provide adequate supervision and safety devices during transfers using the sit to stand mechanical lift, resulting in a resident fall and bilateral hip fractures.
Failure to apply safety straps on the sit to stand lift for residents at risk for falls during transfers.
Report Facts
Residents sampled for accidents: 4
Resident census: 88
Resident weight: 300
Mental status score: 15
Mental status score: 14
Mental status score: 9
Mental status score: 10
Mental status score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Nursing Staff | Expected direct care staff to use safety straps on all transfers and was nurse on duty when resident fell |
| Staff B | Administrative Nursing Staff | Confirmed safety strap use policy and that no residents currently refuse straps |
| Staff E | Consultant Staff | Responsible for training facility staff on safe transfers with mechanical lifts |
| Staff F | Direct Care Staff | Reported training included use of both straps; admitted not using straps if residents refused |
| Staff G | Direct Care Staff | Trained to use both straps but quit using them due to resident refusals |
| Staff D | Direct Care Staff | Reported requirement to use straps unless resident refuses; had not reported refusals to nurses |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Dec 15, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency in the facility to be a 'G' level. As a result, enforcement remedies including denial of payment for new Medicare and Medicaid admissions will be imposed until substantial compliance is achieved.
Deficiencies (1)
Most serious deficiency found at 'G' level
Report Facts
Denial of Payment effective date: Mar 15, 2016
Termination recommendation date: Jun 15, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 4, 2015
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of 12/04/2015. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency under regulation 28-39-158(a) previously cited
Report Facts
Deficiencies corrected: 1
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 4, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers were corrected as of the revisit date of 12/04/2015.
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Nov 11, 2015
Visit Reason
This document is a Plan of Correction submitted by Lakepoint Nursing Center Augusta in response to deficiencies cited during a survey inspection.
Findings
The facility was cited for multiple deficiencies including failure to provide planned activities, inadequate housekeeping and maintenance, failure to review and revise care plans, insufficient monitoring of skin conditions and pressure ulcer prevention, unsanitary food storage and preparation, and inadequate infection control practices. The facility outlined corrective actions and measures to prevent recurrence for each deficiency.
Deficiencies (8)
Failure to provide Resident #27 activities as care planned
Failure to provide necessary housekeeping and maintenance services to maintain a sanitary and homelike environment
Failure to review and revise care plans for Residents #37 and #125 for incontinence and pressure ulcers
Failure to monitor skin conditions and report bruises for Residents #80 and #60
Failure to implement effective interventions to prevent pressure ulcers for Residents #40 and #125
Failure to store and serve food in a sanitary manner
Failure to clean resident rooms to prevent spread of infection
Failure to maintain services of a full-time certified dietary manager to ensure clean and sanitary dietary department
Report Facts
Date for substantial compliance: Dec 4, 2015
Date of Plan of Correction review by Quality Assurance Performance Improvement Committee: Nov 11, 2015
Date Certified Dietary Manager to begin duties: Dec 1, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Dinsmore | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction |
Inspection Report
Enforcement
Deficiencies: 1
Date: Nov 6, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 4, 2015.
Deficiencies (1)
'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date of substantial compliance: Dec 4, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 7
Date: Nov 6, 2015
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation (#85906) to assess compliance with regulatory requirements.
Complaint Details
The inspection was triggered by a complaint investigation #85906.
Findings
The facility was found deficient in multiple areas including failure to provide adequate activities for residents, inadequate housekeeping and maintenance services, failure to review and revise care plans for residents with incontinence and pressure ulcers, failure to monitor skin conditions adequately, failure to prevent pressure ulcers, unsanitary food storage and preparation conditions, and inadequate infection control practices related to cleaning and linen handling.
Deficiencies (7)
Failure to provide activities to meet the interests and psychosocial needs of a cognitively impaired resident.
Failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
Failure to review and revise the plan of care for residents with incontinence and pressure ulcers.
Failure to ensure monitoring of skin conditions for residents, including failure to identify, report, document, and monitor bruising.
Failure to implement effective interventions to prevent development of pressure ulcers for residents at risk.
Failure to store, prepare, and serve food under sanitary conditions, including use of unpasteurized eggs and dirty kitchen equipment.
Failure to maintain an infection control program that prevents spread of infection, including inadequate cleaning of resident rooms and improper handling of linens.
Report Facts
Residents reviewed for sample: 17
Resident census: 74
Braden risk score: 18
Pressure ulcer size: 1.2
Pressure ulcer size: 0.5
Blister size: 7
Blister size: 4
Bruise size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Direct Care Staff | Reported on resident #27's care and activities, and assisted with toileting of resident #37. |
| Staff H | Activity Staff | Attempted to provide sensory stimulation to resident #27. |
| Staff M | Direct Care Staff | Reported on evening activities and resident #27's participation. |
| Staff C | Licensed Nursing Staff | Completed wound and skin care assessments and investigated bruising on resident #80. |
| Staff B | Administrative Nursing Staff | Provided information on admission assessments and wound care procedures. |
| Staff U | Housekeeping Staff | Observed cleaning resident rooms and handling linens. |
| Staff P | Consultant Dietary Staff | Reported on food safety issues including use of unpasteurized eggs and dirty kitchen equipment. |
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 6, 2015
Visit Reason
The visit was a licensure resurvey of the facility to assess compliance for renewal of the license.
Findings
The licensure resurvey resulted in a finding of no deficiency citations.
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 30, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required and enforcement remedies were recommended.
Deficiencies (1)
Most serious deficiencies found were 'F' level, widespread, with no harm but potential for more than minimal harm.
Report Facts
Enforcement effective date: Oct 30, 2015
Provider agreement termination date: Jan 30, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the report and is the enforcement coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for informal dispute resolution process. |
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Aug 27, 2014
Visit Reason
This revisit report documents the correction of deficiencies previously cited during an earlier survey and confirms the dates when corrective actions were completed.
Findings
The report shows that previously identified deficiencies under regulations 28-39-158(g) and 26-40-304(c)(1)(a)(b)(c) were corrected as of 08/27/2014.
Deficiencies (2)
Deficiency under regulation 28-39-158(g)
Deficiency under regulation 26-40-304(c)(1)(a)(b)(c)
Report Facts
Correction completion date: Aug 27, 2014
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 27, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report shows that all previously identified deficiencies with regulation numbers 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.15(h)(2), 483.35(i), and 483.70(c)(2) were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Aug 6, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey.
Findings
The facility has developed and implemented a system to assure correction and continued compliance with regulations, including staff training on abuse and neglect policies, equipment maintenance, and cleaning procedures.
Deficiencies (5)
Deficiencies cited during the survey requiring facility-wide corrective actions.
Policies reviewed with nursing staff regarding abuse and neglect and mandatory reporting.
Maintenance Director hired outside carpet cleaning to fix frayed carpet and staff trained on spill cleanup and reporting.
Reviewed policies and procedures for equipment inspection, cleaning, and replacement; equipment repaired or removed as needed.
Equipment requested to be repaired and staff in-serviced to report malfunctioning equipment immediately.
Report Facts
Complete Date: Aug 27, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Traci Hayden | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 4
Date: Jul 28, 2014
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements, including investigation and reporting of abuse allegations and facility maintenance.
Findings
The facility failed to investigate and report an allegation of resident abuse, maintain housekeeping and maintenance services resulting in stained and frayed carpeting, prepare and serve food under sanitary conditions, and maintain food preparation equipment in safe operating condition.
Deficiencies (4)
Failed to investigate and report an allegation of abuse related to a resident altercation.
Failed to provide necessary housekeeping and maintenance services, resulting in stained and frayed carpeting in multiple areas.
Failed to prepare and serve food under sanitary conditions, including unclean kitchen equipment and surfaces.
Failed to maintain food preparation equipment in safe operating condition; stove oven door seals were not intact.
Report Facts
Census: 90
Sample size: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Nursing Staff | Interviewed regarding the incident involving resident behavior |
| Staff A | Social Services Staff | Interviewed regarding follow-up procedures for resident behaviors |
| Staff I | Dietary Staff | Interviewed regarding kitchen sanitation and equipment cleaning |
| Administrative Staff E | Interviewed about awareness and investigation of the resident incident | |
| Administrative Staff H | Interviewed about facility policies and carpet replacement plans |
Inspection Report
Renewal
Census: 30
Deficiencies: 3
Date: Jul 28, 2014
Visit Reason
The inspection was conducted as a health facility relicensure survey to assess compliance with sanitary and environmental standards.
Findings
The facility failed to store food at proper temperatures as recommended by manufacturers, risking food borne illness, and failed to maintain clean and sanitary conditions in common areas, including stained and discolored carpets.
Deficiencies (3)
Failure to store food in the refrigerator as recommended by the manufacturer to prevent food borne illness.
Failure to maintain flooring in dietary and food preparation areas to be easily cleaned, water-resistant, greaseproof, and free of spaces that can harbor rodents and insects.
Failure to maintain the carpet in common resident living areas in a clean and sanitary manner, with multiple stained and discolored areas observed.
Report Facts
Census: 30
Inspection Report
Enforcement
Deficiencies: 1
Date: Jul 28, 2014
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective August 27, 2014.
Deficiencies (1)
'F' level deficiencies, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date of substantial compliance: Aug 27, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Apr 2, 2014
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that deficiencies previously cited under regulations 483.20(d), 483.20(k)(1), and 483.25(h) have been corrected as of 04/02/2014.
Deficiencies (2)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 2
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Mar 14, 2014
Visit Reason
The inspection was conducted as a complaint investigation related to allegations concerning the facility's failure to develop and implement appropriate care plans and provide adequate assistive devices to prevent falls.
Complaint Details
The findings represent the results of complaint investigations numbered 73458, 73348, and 73349. The complaint was substantiated as the facility failed to prevent a resident fall due to lack of foot pedals on the wheelchair during staff transport.
Findings
The facility failed to develop a comprehensive care plan including the use of foot pedals on a resident's wheelchair during staff transport, resulting in a fall and injury. The facility also failed to provide appropriate assistive devices to prevent the fall, causing the resident to sustain skin tears and bruising.
Deficiencies (2)
Failed to develop a plan of care to include the use of assistive devices during wheelchair transport to prevent falls for 1 of 3 sampled residents.
Failed to provide appropriate assistive devices to prevent a fall for 1 sampled resident, resulting in injury.
Report Facts
Resident census: 87
Sample size: 3
Fall risk assessment score: 14
Skin tear size: 3
Skin tear size: 1.5
Skin tear size: 2.5
Skin tear size: 1.5
Steristrips count: 4
Steristrips count: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Nursing Staff | Reported the resident fell due to lack of foot pedals on wheelchair |
| Staff B | Licensed Nursing Staff | Reported resident had been at facility since 2010 and acknowledged the need for foot pedals |
| Staff D | Licensed Nursing Staff | Reported resident usually had foot pedals in place |
| Staff E | Direct Care Staff | Reported resident did not self propel wheelchair and always had foot pedals |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 14, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey conducted at LakePoint Augusta on March 14, 2014.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint investigation survey at LakePoint Augusta.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, focusing on accurate completion of resident care plans and ensuring residents have necessary assistance devices to prevent accidents.
Deficiencies (2)
Failure to accurately complete the resident care plan to describe services to maintain residents' highest practicable well-being.
Failure to ensure residents have assistance devices to prevent accidents as needed.
Report Facts
Complete Date: Apr 2, 2014
In-service Date: Mar 21, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Traci Hayden | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added Plan of Correction | |
| Mary Jane Kennedy | Modified Plan of Correction |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jan 7, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required to address these deficiencies.
Deficiencies (1)
Isolated 'D' level deficiencies related to Life Safety Code compliance
Report Facts
Denial of payments effective date: Apr 7, 2014
Provider agreement termination date: Jul 7, 2014
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Traci Hayden | Administrator | Facility administrator named in the report |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: May 10, 2013
Visit Reason
This document is a Plan of Correction submitted by LakePoint Augusta in response to deficiencies cited during a prior survey.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations. Specific deficiencies related to quality of care, resident repositioning, and proper cleaning/sanitizing of dining room tables were addressed with staff training and ongoing monitoring.
Deficiencies (3)
Deficiency related to quality of care regarding positioning and range of motion.
Deficiency related to resident repositioning to promote and manage good skin integrity.
Deficiency related to proper cleaning/sanitizing of dining room tables to ensure resident safety.
Inspection Report
Follow-Up
Deficiencies: 3
Date: May 10, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report shows that all previously identified deficiencies with ID prefixes F0309, F0314, and F0323 were corrected as of 05/10/2013.
Deficiencies (3)
Deficiency with ID prefix F0309 related to regulation 483.25
Deficiency with ID prefix F0314 related to regulation 483.25(c)
Deficiency with ID prefix F0323 related to regulation 483.25(h)
Report Facts
Deficiencies corrected: 3
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 3
Date: Apr 15, 2013
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation #64044 to assess compliance with care and safety regulations at Lakepoint Nursing Center.
Complaint Details
The visit was triggered by complaint investigation #64044. The findings included substantiated failures in care and safety practices related to resident positioning, pressure sore prevention, and environmental safety.
Findings
The facility failed to provide necessary care and services to maintain residents' highest well-being, including failure to provide proper positioning devices and interventions for residents with dementia, inadequate repositioning to prevent pressure sores, and failure to ensure a safe environment free of accident hazards, specifically related to unsafe sanitizing practices in the dining room.
Deficiencies (3)
Failure to provide interventions and positioning devices for residents to maintain good body alignment.
Failure to provide adequate repositioning to prevent pressure sores for a resident.
Failure to ensure residents remained free of accident hazards while eating, including spraying sanitizer on tables while residents were present.
Report Facts
Census: 83
Residents reviewed for activities of daily living/positioning: 3
Residents reviewed for repositioning: 3
Time resident remained in geri-chair without repositioning: 5
Time between initial seating and transfer to bed: 3.75
Sanitizer concentration: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager C | Reported facility dining practices and sanitizer use. | |
| Direct Care Staff E | Reported use of stuffed toys for resident positioning and participated in resident transfers. | |
| Direct Care Staff I | Reported on resident positioning devices and participated in resident transfers. | |
| Direct Care Staff J | Participated in resident transfers. | |
| Direct Care Staff K | Participated in resident transfers. | |
| Direct Care Staff G | Reported on resident repositioning practices. | |
| Direct Care Staff F | Participated in resident transfers. | |
| Dietary Staff D | Observed spraying sanitizer on tables while residents ate. | |
| Dietary Staff E | Observed spraying sanitizer on tables while residents ate. | |
| Therapy Staff L | Reported on resident's increased tone and quarterly assessments. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N008005 POC 25KZ11
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, including reviewing policies on food storage and labeling, and addressing carpet cleaning and maintenance issues.
Deficiencies (2)
Improper storage and labeling of foods in the dietary refrigerator.
Frayed carpet area requiring professional cleaning and staff training on spill cleanup and reporting.
Report Facts
Complete Date for Plan of Correction: Aug 27, 2014
Mandatory In-service Date: Aug 7, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Traci Hayden | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N008005 POC JYIQ11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 5.29.19.
Findings
The facility has developed and implemented a facility-wide system to assure correction and continued compliance with regulations. Staff education and ongoing monitoring by the Interdisciplinary Team (IDT) are part of the corrective actions.
Deficiencies (2)
Facility-wide system developed and implemented to assure correction and compliance.
Interdisciplinary Team and nursing staff educated on interventions to ensure adherence to resident care plans.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Charlotte Claar | Administrator | Submitted the Plan of Correction to KDADS. |
| Janice VanGotten | Added and modified the Plan of Correction. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: N008005 POC S7YG11
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, including re-education of licensed nursing staff on wound management, antibiotic stewardship, infection prevention, and visual monitoring policies.
Deficiencies (3)
Deficiency related to wound management and treatment of pressure ulcers
Deficiency related to antibiotic stewardship and infection prevention/control program
Deficiency related to nurses station visual monitoring policy
Report Facts
Complete Date: Sep 26, 2019
Complete Date: Oct 25, 2019
Complete Date: Sep 26, 2019
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