Inspection Reports for Lakepoint El Dorado LLC

An offsite revisit was conducted to verify correction of all previous deficiencies cited on 12/12/2019.

All deficiencies have been corrected as of the compliance date of 01/10/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

Annual health resurvey of Lakepoint El Dorado, LLC nursing facility to assess compliance with regulatory requirements including resident care, medication administration, infection control, and facility environment.

The facility was found deficient in multiple areas including failure to provide bed hold notification upon resident transfer, inadequate personal care for dependent residents, failure to provide necessary respiratory care, medication administration errors including failure to administer ordered medications and failure to monitor drug regimens, unsanitary food storage practices, inadequate infection prevention and control practices related to linen handling, failure to provide influenza and pneumococcal vaccine education and administration, and maintenance deficiencies in the laundry area.

This document is a Plan of Correction submitted by LakePoint El Dorado in response to deficiencies cited during the survey conducted on 12/03/2019.

The Plan of Correction outlines corrective actions for multiple deficiencies related to bed hold policy, resident care preferences, respiratory equipment storage, medication management, lab order audits, medication room refrigerator maintenance, soiled linen handling, immunization procedures, and laundry room maintenance.

An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-06-05.

All deficiencies cited in the previous inspection have been corrected as of the compliance date 2019-07-05, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was conducted as a complaint investigation (#141115) to evaluate the facility's compliance with accident hazard prevention and resident supervision requirements.

The facility failed to provide adequate planned assistance with transfers and walking for one resident, resulting in a fall. There was a communication problem between shifts leading to insufficient staff assistance during ambulation, increasing the risk of repeated falls.

The complaint investigation #141115 found that the facility did not provide adequate assistance of two staff with a gait belt for the resident, leading to a fall and risk of repeated falls.

A Recertification and Complaint Investigation survey was conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department for Aging and Disability Services (KDADS). The complaints investigated, KS00135564 and KS00136009, were both found to be unsubstantiated.

The facility was found to be in substantial compliance with 42 CFR 483 subpart B. Both complaints investigated were unsubstantiated.

Complaints KS00135564 and KS00136009 were investigated and found to be unsubstantiated.

A recertification and complaint investigation survey was conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department for Aging and Disability Services (KDADS).

The complaints investigated, KS00135564 and KS00136009, were both found to be unsubstantiated. The facility was found to be in substantial compliance with 42 CFR 483 subpart B.

Complaints KS00135564 and KS00136009 were investigated and found to be unsubstantiated.

The visit was conducted as a complaint investigation (#130418) at the facility.

The complaint investigation resulted in a finding of no deficiency citation with respect to applicable regulations under 42 CFR Part 483, Subpart B, requirements for long term care facilities.

Complaint investigation #130418 resulted in no deficiency citation.

The visit was conducted as a complaint investigation (#130418) at the facility.

The complaint investigation resulted in a finding of no deficiency citation with respect to applicable regulations under 42 CFR Part 483, Subpart B, requirements for long term care facilities.

Complaint investigation #130418 resulted in no deficiency citation.

This document is a Plan of Correction submitted in response to a complaint investigation #130418 for the facility Lakepointe El Dorado.

The complaint investigation resulted in a finding of no deficiency citation with respect to applicable regulations under 42 CFR Part 483, Subpart B, requirements for long term care facilities.

Complaint investigation #130418 resulted in no deficiency citation.

A revisit survey was conducted on 3/23/2018 for all previous deficiencies cited on 1/8/2018.

All deficiencies have been corrected as of the compliance date of 2/7/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

A revisit survey was conducted on 3/23/2018 for all previous deficiencies cited on 1/8/2018.

All deficiencies have been corrected as of the compliance date of 2/7/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.

All previously cited deficiencies identified by regulation numbers 26-41-101 (f)(3), 26-41-201 (d), 26-41-202 (a), 26-41-204 (e), 26-41-205 (d)(1-2), and 26-41-205 (d)(4) were corrected as of the revisit date.

The inspection was a resurvey with investigation of complaint #121776 at the assisted living facility conducted on 1/16/18, 1/17/18, and 1/18/18.

The facility was found deficient in multiple areas including failure to report an allegation of resident abuse within 24 hours, inaccurate functional capacity screening, incomplete negotiated service agreements, improper delegation of nursing procedures, and failure to administer medications according to physician orders. Specific issues involved resident #480's abuse allegation not reported timely, resident #450's functional capacity screen inaccuracies, missing payment source in service agreements for residents #450 and #460, lack of licensed nurse delegation for blood sugar testing and insulin pen preparation to medication aides, and medication administration errors for resident #450.

The complaint investigation involved allegations of resident abuse related to resident #480, specifically regarding inappropriate transfer and dragging of the resident by staff. The facility failed to report this allegation to the department within 24 hours as required.

This document is a Plan of Correction submitted by LakePoint El Dorado in response to deficiencies cited during a prior survey.

The Plan of Correction details corrective actions taken and planned by the facility to address multiple deficiencies related to resident care plans, medication management, staffing, infection control, dietary sanitation, and safety measures. The facility outlines education, audits, monitoring, and policy changes to ensure compliance.

The inspection was a Health Resurvey and Complaint Investigations for multiple complaint numbers.

The facility had multiple deficiencies including failure to accommodate resident needs for smoking out of weather, incomplete baseline care plans, failure to revise care plans after assessments, inadequate supervision leading to falls and injuries, insufficient nurse staffing, lack of required nurse aide in-service training, failure to post nurse staffing information, unsanitary food storage and preparation conditions, incomplete facility-wide assessment, infection control failures including improper nebulizer cleaning and hand hygiene, and failure to implement an antibiotic stewardship program.

The visit was a non-compliance revisit to the facility to determine if previous deficiencies had been corrected.

The revisit resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.

This document is a Plan of Correction submitted in response to deficiencies identified during the Lakepoint El Dorado federal revisit inspection on 2017-09-08.

All deficiencies identified in the prior inspection were corrected as of 2017-09-08.

The visit was a non-compliance revisit to the facility to determine if previous deficiencies had been corrected.

The revisit resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.

The inspection was conducted as a complaint investigation survey #118797 to evaluate the facility's compliance with accident hazard prevention and resident supervision requirements.

The facility failed to ensure the safety of one resident during transfers, resulting in two falls and subsequent acute compression fractures of the back. Staff failed to use a gait belt during transfers as required by facility policy, leading to unsafe transfers and injury.

The complaint investigation found that the facility failed to provide safe transfers for resident #1, who fell twice due to staff not using a gait belt, resulting in two compression fractures. The resident was cognitively impaired and required assistance with transfers. The facility investigation confirmed staff negligence in using gait belts during transfers.

An Abbreviated survey was conducted by the Kansas Department for Aging and Disability Services 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 most serious deficiency at a level of actual harm that is not immediate jeopardy, requiring corrections. Based on these deficiencies, the facility will not be given an opportunity to correct before enforcement remedies are imposed, including denial of payment for new Medicare and Medicaid admissions effective August 29, 2017.

The document is a Plan of Correction submitted in response to deficiencies cited during a prior survey of LakePoint El Dorado facility.

The facility developed and implemented a system to assure correction and continued compliance with regulations, specifically addressing safe resident transfers and gait belt use.

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.

The revisit confirmed that the previously cited deficiencies, including those under regulation 483.60(a),(b), were corrected as of the revisit date.

The inspection was conducted as a result of complaint investigations #103420 and #103720 regarding medication administration issues.

The facility failed to ensure that one resident (#3) received intravenous antibiotic medication (Vancomycin) as ordered by the physician. Specifically, three doses of the medication were missed from 8/3/16 to 8/5/16, with the resident only receiving the evening dose instead of the prescribed twice daily doses.

The visit was complaint-related, investigating allegations that the facility failed to administer intravenous antibiotic medications as ordered. The complaint investigations were #103420 and #103720. The deficiency was substantiated with evidence of missed doses and failure to obtain physician-ordered laboratory tests.

This document is a Plan of Correction submitted in response to a complaint investigation related to a medication error at the facility.

The facility identified a medication error involving resident #3 where the time code for medication administration was incorrect, leading to inaccurate lab results. Corrective actions include notifying the physician, resident, and DPOA, in-servicing nurses on medication change procedures, and ongoing audits by the Director of Nursing.

Complaint investigation related to medication error involving resident #3; the physician, resident, and DPOA were notified. The plan of correction addresses the error and outlines steps to prevent recurrence.

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.

The survey found the most serious deficiency to be a 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 based on the credible allegation of compliance and the plan of correction.

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.

All previously cited deficiencies identified by regulation numbers were corrected as of the revisit date, with completion dates noted as 06/02/2016.

The inspection was conducted as a Health Resurvey and Complaint Investigation #97759 to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including failure to notify legal representatives and physicians of medication errors, failure to provide resident bathing choices, failure to develop individualized comprehensive care plans especially for hospice coordination, failure to revise care plans to prevent falls, failure to maintain accident-free environment with adequate supervision and assistance devices, and failure to follow physician orders in medication administration and monitoring.

The inspection included a complaint investigation as indicated by the report referencing Complaint Investigation #97759.

This document is a Plan of Correction submitted in response to a prior inspection report for the facility identified as ASPEN Event ID K1JC11.

No deficiencies were cited in the related inspection report dated 05/03/2016.

This document is a Plan of Correction submitted by Lakepoint Nursing and Rehab Center El Dorado in response to deficiencies cited during a prior inspection on 05/03/2016.

The Plan of Correction addresses multiple deficiencies including medication errors, bathing choices, individualized care plans for hospice residents, fall risk interventions, and medication regimen reviews. The facility outlines corrective actions such as policy reviews, staff education, audits, and care plan updates to ensure substantial compliance by 06/02/2016.

The visit was a Licensure Resurvey and Complaint Investigations #94114 and #93655 of the facility.

The investigations resulted in a finding of no deficiency citations.

Complaint Investigations #94114 and #93655 were conducted and found no deficiencies.

A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found isolated 'D' level deficiencies that constituted no actual harm but had potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective June 2, 2016.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

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

This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation.

The facility was cited for insufficient 24-hour nursing staff per care plans, specifically regarding timeliness of answering call lights promptly.

This Plan of Correction is related to a complaint investigation identified by Event ID K9FX11 and Complaint ID 082115.

This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that the deficiency identified by ID Prefix F0353 under regulation 483.30(a) was corrected on 09/11/2015. No other deficiencies are listed.

The inspection was conducted as a complaint investigation (#90367) regarding concerns about the facility's nursing staff response to resident call lights.

The facility failed to respond timely to a resident's call light for toileting assistance, resulting in a delay of over 30 minutes. Interviews with residents and staff confirmed slow response times to call lights.

Complaint investigation #90367 found that the facility nursing staff failed to respond timely to a resident's call light, with documented delays of over 30 minutes. Residents reported slow staff response to call lights.

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.

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

This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The revisit confirmed that all previously reported deficiencies identified by their regulation numbers and prefix codes were corrected as of 02/12/2015.

This report is a revisit conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.

The report confirms that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 02/12/2015.

A Health survey was conducted by the Kansas Department for Aging & Disability Services to determine compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.

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 February 12, 2015.

The inspection was conducted as a Health Licensure Resurvey to assess compliance with dietary services regulations.

The facility failed to employ a full-time certified dietary manager to oversee the dietary department and had multiple sanitation issues in the kitchen, including debris and sticky substances on food bins, water held between stacked pans, residue on utensils, stained coffee mugs, worn varnish on dining room surfaces, and cracked dish drying bins.

The Health Licensure Resurvey was conducted as a renewal inspection of the facility.

The resurvey resulted in a finding of no deficiency citations.

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.

The survey found isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required, and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.

This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-10-02.

The report shows that all previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of 2013-10-16.

The inspection was conducted as a health resurvey and complaint investigation involving multiple complaint numbers (#67812, #68272, #67875, #68938, and #67618).

The facility was found deficient in multiple areas including failure to post state ombudsman information, failure to serve palatable food at proper temperatures, failure to maintain sanitary food storage and preparation conditions, and failure to maintain a consistent infection control program with proper surveillance and documentation.

The visit was complaint-related involving multiple complaint numbers (#67812, #68272, #67875, #68938, and #67618). The complaint investigation revealed deficiencies in resident rights notification, food service quality and safety, and infection control practices.

The licensure survey was conducted to assess compliance for the facility's licensing requirements.

The survey resulted in a finding of no deficiency citations for the facility.

This is a post-certification revisit to verify that previously cited deficiencies have been corrected as shown on the CMS-2567 Statement of Deficiencies and Plan of Correction.

All previously reported deficiencies identified by regulation numbers 483.15(e)(1), 483.25(i), 483.25(j), 483.25(l), 483.55(b), and 483.60(c) were corrected as of the revisit date.

This document is a Plan of Correction submitted by LakePoint Nursing Center in response to deficiencies cited during a health facility resurvey (#1455) and investigations of complaints (#57603 and #57167).

The facility developed and implemented corrective actions addressing bathing preferences, nutritional programs, hydration, monitoring of orthostatic blood pressures for residents on psychoactive medications, dental services, and behavior monitoring related to psychoactive medications with Black Box Warnings.

The Plan of Correction addresses deficiencies cited from investigations of complaints #57603 and #57167.

The health facility resurvey and investigation of complaints #57603 and #57167.

The facility failed to provide reasonable accommodation for resident bathing preferences, failed to maintain nutritional status for multiple residents, failed to provide sufficient hydration for residents at risk, failed to provide appropriate dental services, and failed to monitor residents on psychoactive medications for behavior and side effects as required.

Investigation of complaints #57603 and #57167.

This document is a Plan of Correction submitted by LakePoint El Dorado in response to deficiencies cited during a prior survey.

The facility developed and implemented a system to assure correction and continued compliance with regulations, specifically addressing safe resident transfers and care plan updates.

This document is a Plan of Correction submitted by LakePoint Nursing & Rehab Center of El Dorado addressing deficiencies cited during a prior survey.

The facility developed and implemented corrective actions for multiple deficiencies related to resident care, transfer assistance, dietary practices, medication management, infection control, and dishwashing procedures, with assigned responsibilities and timelines for completion.

This document is a Plan of Correction submitted by LakePoint Nursing Center in response to deficiencies cited during a health facility resurvey.

The facility has developed and implemented corrective actions addressing deficiencies related to resident notice, meal service, kitchen sanitation, and infection control. Actions include staff inservices, equipment cleaning and replacement, and ongoing monitoring by the Administrator and Certified Dietary Manager.