Inspection Reports for
Lakepoint El Dorado LLC
1313 S HIGH STREET, EL DORADO, KS, 67042-3751
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
13.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
118% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
85% occupied
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 55
Deficiencies: 13
Date: Dec 18, 2024
Visit Reason
Routine inspection of Lakepoint El Dorado, LLC nursing home to assess compliance with regulatory requirements including resident care, medication management, safety, and hospice services.
Findings
The facility failed to provide timely written notification of transfers/discharges to residents and representatives, failed to provide bed hold policy copies upon transfers, failed to develop comprehensive care plans for dialysis and diabetes, failed to follow up with physicians timely, failed to prevent falls due to equipment and toileting issues, failed to monitor fluid restrictions, failed to identify trauma triggers and implement trauma-informed care, failed to ensure consultant pharmacist identified medication irregularities, failed to hold blood pressure medications per orders, failed to ensure appropriate use of antipsychotics, had medication storage and monitoring deficiencies, and failed to ensure collaboration with hospice providers.
Deficiencies (13)
F0623: The facility failed to provide timely written notification to residents and representatives for facility-initiated transfers or discharges, placing residents at risk for impaired rights and uninformed care choices.
F0625: The facility failed to provide residents with a copy of the bed hold policy upon transfer to hospital, risking residents not being permitted to return and resume residence.
F0656: The facility failed to develop and implement comprehensive care plans for residents with dialysis and diabetes mellitus, placing residents at risk of impaired care due to uncommunicated care needs.
F0684: The facility failed to follow up with the physician for direction when a resident had a productive cough and coarse lung sounds, risking physical decline and complications.
F0689: The facility failed to ensure a resident's low air-loss mattress was functioning, resulting in an avoidable fall, and failed to assess toileting needs after falls, placing residents at risk for further falls and injury.
F0692: The facility failed to monitor and document compliance with physician-ordered fluid restriction for a resident, placing the resident at risk of fluid overload and related complications.
F0699: The facility failed to identify trauma-based triggers and implement individualized interventions for a resident with PTSD, risking decreased psychosocial well-being and ineffective treatment.
F0756: The facility failed to ensure the consultant pharmacist identified and reported medication irregularities including blood pressure medications given outside ordered parameters and antipsychotic use without approved diagnosis, placing residents at risk for inappropriate medication use and complications.
F0757: The facility failed to hold blood pressure medications per physician orders when blood pressure was out of parameters for two residents, placing residents at risk for physical decline and complications.
F0758: The facility failed to hold blood pressure medications per physician orders for a resident, placing the resident at risk of unnecessary medication use and related complications.
F0759: The facility failed to ensure medication error rate was less than 5%, with a 16% error rate observed due to blood pressure medications given outside ordered parameters, placing residents at risk for physical decline and complications.
F0761: The facility failed to ensure medications and biologicals were stored and monitored appropriately in medication room refrigerators, including failure to record temperatures and presence of expired items, placing residents at risk of ineffective medication.
F0849: The facility failed to ensure collaboration of care between hospice provider and facility for residents on hospice, lacking detailed care plans and communication, placing residents at risk of inadequate end-of-life care.
Report Facts
Census: 55
Medication administrations observed: 25
Medication error rate: 16
Fluid restriction: 1200
Blood pressure parameters: 120
Blood pressure parameters: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified medication errors, bed hold policy issues, and hospice collaboration deficiencies |
| Licensed Nurse G | Licensed Nurse | Provided statements on notification practices and hospice services |
| Certified Medication Aide R | Certified Medication Aide | Administered medications outside blood pressure parameters |
| Licensed Nurse H | Licensed Nurse | Reviewed care plans and medication administration for compliance |
| Certified Nurse Aide N | Certified Nurse Aide | Provided information on hospice and mattress monitoring |
Inspection Report
Routine
Census: 55
Deficiencies: 13
Date: Dec 18, 2024
Visit Reason
Routine inspection of Lakepoint El Dorado, LLC nursing home to assess compliance with regulatory requirements including medication management, resident care, hospice services, and safety.
Findings
The facility failed to provide timely written notification of transfers/discharges to residents and their representatives, failed to provide bed hold policy copies upon discharge, failed to develop comprehensive care plans for dialysis and diabetes, failed to follow up with physicians timely, failed to prevent falls related to equipment and toileting needs, failed to monitor fluid restrictions, failed to identify trauma triggers and implement trauma-informed care, failed to ensure consultant pharmacist identified medication irregularities, failed to hold blood pressure medications per physician orders, failed to ensure proper medication storage and monitoring, and failed to ensure collaboration with hospice providers.
Deficiencies (13)
F0623: The facility failed to provide timely written notification to residents and representatives of facility-initiated transfers or discharges, placing residents at risk for impaired rights and uninformed care choices.
F0625: The facility failed to provide residents with a copy of the bed hold policy upon transfer or discharge, placing residents at risk for loss of bed and residence.
F0656: The facility failed to develop and implement comprehensive care plans for residents with dialysis and diabetes mellitus, placing residents at risk for impaired care due to uncommunicated needs.
F0684: The facility failed to follow up with the physician for direction when a resident had a productive cough, placing the resident at risk for physical decline and complications.
F0689: The facility failed to ensure a resident's low air-loss mattress was functioning, resulting in an avoidable fall, and failed to assess toileting needs after falls, placing residents at risk for injury.
F0692: The facility failed to monitor and document compliance with physician-ordered fluid restriction for a resident, placing the resident at risk for fluid overload and complications.
F0699: The facility failed to identify trauma-based triggers and implement individualized interventions for a resident with PTSD, placing the resident at risk for decreased psychosocial well-being.
F0756: The facility failed to ensure the consultant pharmacist identified and reported medication irregularities including blood pressure medications given outside ordered parameters and antipsychotic use without approved indication, placing residents at risk for inappropriate medication use.
F0757: The facility failed to hold blood pressure medications per physician orders when blood pressure was out of parameters for two residents, placing residents at risk for physical decline and complications.
F0758: The facility failed to hold blood pressure medication lisinopril when blood pressure was out of physician-ordered parameters, placing the resident at risk of unnecessary medication.
F0759: The facility failed to ensure medication error rate was less than 5%, with a 16% error rate observed related to blood pressure medications given outside parameters, placing residents at risk for physical decline and complications.
F0761: The facility failed to ensure medications and biologicals were stored and monitored appropriately, including refrigerator temperature monitoring and disposal of expired items, placing residents at risk of ineffective medication.
F0849: The facility failed to ensure collaboration of care between hospice providers and the facility for two residents, placing residents at risk of inadequate end-of-life care.
Report Facts
Census: 55
Medication administrations observed: 25
Medication error rate: 16
Fluid restriction: 1200
Medication doses given outside parameters: 16
Expired yogurts: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified medication errors, lack of notification, and hospice collaboration issues |
| Licensed Nurse G | Licensed Nurse | Provided statements about notification practices and hospice services |
| Certified Medication Aide R | Certified Medication Aide | Administered medications to R18 and acknowledged medication error |
| Licensed Nurse H | Licensed Nurse | Reviewed care plans and medication administration for residents R29 and R18 |
| Certified Nurse Aide N | Certified Nurse Aide | Provided information about hospice and resident care |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Date: Jul 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent sexual abuse of a cognitively impaired resident by another resident.
Complaint Details
The complaint investigation was triggered by reports and observations of Resident 2 touching Resident 3 inappropriately. The facility made a police report and state notification and conducted an investigation. Resident 2 was discharged from the facility following the incident. The abuse was substantiated and placed Resident 3 at immediate jeopardy.
Findings
The facility failed to prevent sexual abuse of Resident 3, who had severe cognitive impairment and lacked the ability to consent, when Resident 2 touched her inappropriately. The facility did not update care plans or adequately document behaviors, placing Resident 3 at immediate jeopardy and risk of trauma.
Deficiencies (2)
F 0600: The facility failed to protect Resident 3 from sexual abuse by Resident 2, who touched her groin area without consent, placing her at immediate jeopardy and risk for trauma and negative psychosocial impact.
F 0610: The facility failed to respond appropriately to the sexual abuse allegation involving Resident 3 and Resident 2, lacking proper documentation and timely intervention, placing Resident 3 at immediate jeopardy.
Report Facts
Residents sampled for abuse: 3
Census: 52
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 6
Date: Feb 16, 2023
Visit Reason
Annual inspection of Lakepoint El Dorado nursing home to assess compliance with regulatory requirements including resident care, medication management, safety, and immunization policies.
Findings
The facility failed to adequately assess and implement fall prevention interventions for residents at risk, failed to assess and ensure safe use of bed side rails for multiple residents, failed to ensure appropriate medication management including lack of stop dates and rationale for psychotropic medications, and failed to provide current year influenza vaccine information statements to residents or their representatives.
Deficiencies (6)
F 0657: The facility failed to review and revise Resident 10's care plan with resident-centered interventions to prevent falls, placing the resident at risk for further falls and injury.
F 0689: The facility failed to ensure Resident 20's wheelchair had an antiroll back device as care planned, placing the resident at risk for further falls.
F 0700: The facility failed to assess bed side rails for safety for Residents 1, 12, 14, 17, 20, and 21, placing them at risk for entrapment and injury.
F 0756: The facility failed to ensure the Consultant Pharmacist identified and reported the lack of a 14 day stop date or rationale for continued use of Resident 26's as needed psychotropic medication, placing the resident at risk for inappropriate medication use.
F 0758: The facility failed to ensure Residents 10 and 26 had required stop dates or documented rationale for continued use of as needed psychotropic medications, placing residents at risk for adverse effects.
F 0883: The facility failed to offer and provide or obtain informed refusals for current year influenza vaccinations and failed to provide the current year Vaccine Information Statements for Residents 4, 12, 17, 20, and 25, increasing risk for illness and infection.
Report Facts
Resident census: 32
Sample residents reviewed: 14
Residents reviewed for side rails: 6
Residents reviewed for unnecessary medications: 6
Residents reviewed for immunization status: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Verified failure to obtain 14 day stop date for Resident 26's psychotropic medication and failure to provide current year VIS for influenza vaccine | |
| Administrative Nurse G | Reported on fall investigations and care plan updates for Resident 10 | |
| Licensed Nurse G | Reported on fall prevention interventions for Resident 10 | |
| CNA M | Certified Nurse Aide | Reported on fall prevention interventions for Resident 10 |
| Administrative Staff A | Verified side rail gaps and assessments for multiple residents |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 4
Date: Aug 17, 2021
Visit Reason
Annual inspection of Lakepoint El Dorado nursing home to assess compliance with care plan development, pressure ulcer management, accident prevention, and other regulatory requirements.
Findings
The facility failed to develop baseline care plans within 48 hours for a newly admitted resident, failed to review and revise care plans related to pressure ulcers, failed to provide appropriate pressure ulcer care including sanitary dressing changes, and failed to ensure accident prevention measures such as foot pedals and anti-lock brakes on wheelchairs were in place.
Deficiencies (4)
F0655: The facility failed to develop a baseline care plan within 48 hours of admission for a resident with multiple health issues.
F0657: The facility failed to review and revise the care plan within 7 days for a resident who developed stage three and four pressure ulcers related to use of a heel lift device.
F0686: The facility failed to provide appropriate pressure ulcer care and sanitary dressing changes for three residents, including failure to perform hand hygiene between glove changes.
F0689: The facility failed to ensure accident prevention by not providing anti-lock brakes on a resident's wheelchair and not placing foot pedals on another resident's wheelchair, resulting in a fall.
Report Facts
Residents selected for review: 16
Residents census: 51
Pressure ulcer measurements: 10
Pressure ulcer measurements: 9.5
Pressure ulcer measurements: 8
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 14, 2020
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 12/12/2019.
Findings
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.
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 10
Date: Dec 12, 2019
Visit Reason
Health resurvey to assess compliance with previously cited deficiencies.
Findings
The facility was found deficient in multiple areas including failure to provide bed hold notification upon resident transfer, inadequate personal care, improper respiratory care, medication administration errors, failure to conduct drug regimen reviews, unsanitary food storage, infection control lapses related to linen handling, failure to provide immunization education and administration, and maintenance issues compromising a safe and sanitary environment.
Deficiencies (10)
F 625: The facility failed to provide evidence of a bed hold notification when Resident 15 was transferred to a hospital for in-patient treatment.
F 677: The facility failed to provide personal care including shaving for Resident 4 who required assistance with facial hair removal.
F 695: The facility failed to provide necessary respiratory care for Residents 15 and 45, including failure to administer nebulizer treatments properly and failure to store and clean respiratory equipment to prevent infection.
F 755: The facility failed to administer medications as ordered to Residents 15 and 49 due to unavailable medications and failure to reorder timely.
F 756: The pharmacist failed to identify and report irregularities including failure to obtain ordered annual lab tests for Resident 1, compromising medication monitoring.
F 757: The facility failed to ensure Resident 1 remained free of unnecessary medications due to failure to obtain ordered lab work to monitor medication effectiveness.
F 812: The facility failed to provide sanitary food storage on the east wing, with undated and expired food items found in a refrigerator used for resident food.
F 880: The facility failed to handle, store, and process linens to prevent cross contamination and infection spread, including uncovered soiled linens and unsanitizable storage surfaces.
F 883: The facility failed to provide annual educational information regarding influenza and pneumococcal vaccines to residents and/or representatives and failed to provide requested vaccines to some residents.
F 921: The facility failed to provide maintenance services to ensure a safe, functional, sanitary, and comfortable environment, including laundry area deficiencies such as missing floor paint, exposed sheet rock, rusty vents, and halted renovations.
Report Facts
Resident census: 57
Residents selected for review: 15
Residents reviewed for medication: 5
Residents reviewed for respiratory care: 2
Residents reviewed for ADL care: 3
Residents on east wing: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Reported on bed hold notification, respiratory care, and linen handling deficiencies. |
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including medication administration, respiratory care, immunization, linen handling, and maintenance issues. |
| Licensed Nurse K | Licensed Nurse | Verified failure to obtain ordered lab work for Resident 1. |
| Licensed Nurse L | Licensed Nurse | Verified failure to obtain ordered lab work and immunization education. |
| Certified Medication Aide M | Certified Medication Aide | Observed improper nebulizer treatment administration. |
| Licensed Nurse H | Licensed Nurse | Observed medication administration and verified medication unavailability. |
| Housekeeping Staff W | Housekeeping Staff | Verified laundry and linen storage deficiencies. |
| Maintenance Staff V | Maintenance Staff | Verified laundry maintenance deficiencies. |
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Dec 3, 2019
Visit Reason
This document is a Plan of Correction submitted by LakePoint El Dorado in response to deficiencies cited during the inspection survey conducted on December 3, 2019.
Findings
The plan outlines corrective actions for multiple deficiencies related to bed hold policies, resident care preferences, respiratory equipment management, medication administration, lab order audits, medication room maintenance, soiled linen handling, immunization procedures, and facility maintenance.
Deficiencies (11)
F0000: Facility developed and implemented a system to assure correction and continued compliance with regulations.
F625-D: Bed hold policy was not properly communicated and documented during resident hospital transfers.
F677-D: Resident shaving frequency preferences were not consistently obtained or monitored.
F695-D: Respiratory equipment was not properly dated, stored, or maintained.
F755-D: Medication availability and administration policies were not fully implemented or audited.
F756-D: Lab orders were not consistently audited to ensure routine labs were scheduled and results received.
F757-D: Duplicate of F756-D regarding lab order audits and monitoring.
F812-E: Medication room refrigerator contained old and unlabeled food items.
F880-F: Soiled linen barrels were uncovered; laundry area maintenance and staff education were needed.
F883-E: Influenza and pneumococcal vaccine education and auditing were not fully implemented.
F921-E: Laundry room maintenance issues including baseboard repair, ceiling vent replacement, and floor painting.
Report Facts
Compliance Date: 2020
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 2, 2019
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-06-05.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2019-07-05. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Jun 5, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#141115) regarding concerns about accident hazards and supervision at the facility.
Complaint Details
This inspection was triggered by complaint investigation #141115. The complaint was substantiated as the facility failed to provide adequate supervision and assistance to prevent accidents.
Findings
The facility failed to provide adequate planned assistance with transfers and walking for one resident, resulting in repeated falls. There was a communication problem between shifts leading to insufficient staff assistance during resident ambulation.
Deficiencies (1)
F 689: The facility failed to provide adequate assistance of two staff with a gait belt for resident #01 to ensure safe transfers and prevent falls. The resident was ambulated by one staff member alone, contrary to care plan requirements.
Report Facts
Resident census: 81
Sample size: 3
Fall incidents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff B | Acknowledged communication problem and assessed resident after fall | |
| Direct care staff D | Assisted resident during fall and was involved in inadequate ambulation | |
| Direct care staff E | Assisted in lifting resident after fall | |
| Direct care staff F and G | Observed assisting resident with gait belt on 6/5/19 |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
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 KS00135564 and KS00136009 were investigated.
Complaint Details
Complaints KS00135564 and KS00136009 were investigated and found to be unsubstantiated.
Findings
Both complaints were found to be unsubstantiated. The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Report Facts
Sample Size: 21
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
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 were KS00135564 and KS00136009.
Complaint Details
The complaints KS00135564 and KS00136009 were investigated and found to be unsubstantiated.
Findings
Both complaints were found to be unsubstantiated. The facility was found to be in substantial compliance with 42 CFR 483 subpart B.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 21, 2018
Visit Reason
The visit was conducted as a complaint investigation (#130418) for the facility.
Complaint Details
Complaint investigation #130418 resulted in no deficiency citation.
Findings
The complaint investigation resulted in a finding of no deficiency citation with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 21, 2018
Visit Reason
The visit was conducted as a complaint investigation (#130418) for the facility.
Complaint Details
Complaint investigation #130418 found no deficiencies.
Findings
The complaint investigation resulted in a finding of no deficiency citation with respect to applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 21, 2018
Visit Reason
This document is a plan of correction submitted in response to a complaint investigation at the facility.
Complaint Details
Complaint investigation #130418 was conducted and resulted in no deficiency citation.
Findings
The complaint investigation #130418 resulted in a finding of no deficiency citation with respect to applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Deficiencies (1)
Complaint investigation #130418 found no deficiency citation under 42 CFR Part 483, Subpart B requirements for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 23, 2018
Visit Reason
A revisit survey was conducted on 3/23/2018 to verify correction of all previous deficiencies cited on 1/8/2018.
Findings
All deficiencies cited in the prior survey have been corrected as of 2/7/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Deficiencies (1)
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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 23, 2018
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-01-08.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2018-02-07, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 21, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for each deficiency.
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Jan 22, 2018
Visit Reason
This document is a Plan of Correction submitted by LakePoint El Dorado in response to deficiencies cited during a prior survey.
Findings
The facility developed and implemented corrective actions addressing multiple deficiencies including resident care plans, medication management, infection control, dietary sanitation, staffing patterns, and safety interventions. The plan outlines specific corrective steps, education, audits, and monitoring to ensure compliance.
Deficiencies (14)
F0000: The facility developed and implemented a system to assure correction and continued compliance with regulations.
F558-E: Residents who smoke were instructed to use a covered area during bad weather to ensure safety.
F655-D: Baseline care plans were reviewed and updated to include necessary interventions such as sleeve protectors and foot pedals.
F657-D: Care plans for residents at risk for falls and constipation were reviewed and revised with appropriate interventions.
F689-G: Care plans for residents at risk for falls were audited and revised; therapy equipment was secured to prevent accidents.
F726-F: Staffing patterns were reviewed to ensure appropriate supervision and communication with residents and staff.
F730-D: A QAPI plan was initiated and staff were in-serviced on abuse, neglect, and exploitation.
F732-C: Licensed staff were educated on posting staffing information and compliance monitoring was established.
F757-D: Medication regimens for residents with constipation were audited and nursing staff educated on bowel protocols.
F758-D: PRN psychotropic medication orders were reviewed and discontinued as appropriate; staff education on management was provided.
F812-F: Dietary sanitation practices were improved including cleaning schedules, equipment maintenance, and monitoring.
F838-F: The facility assessment was started and scheduled for completion with annual updates.
F880-F: Nebulizer components were replaced and infection control logs corrected; staff competencies in hand hygiene were established.
F881-F: The Antibiotic Stewardship program was reviewed and core elements ensured; staff education on stewardship criteria was provided.
Report Facts
Compliance Date: Feb 7, 2018
Resident IDs referenced: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christie Underwood | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 6
Date: Jan 18, 2018
Visit Reason
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.
Complaint Details
The complaint investigation involved allegations of resident abuse related to improper transfer of resident #480 and failures in reporting the abuse to the department within 24 hours. The allegation was substantiated as the operator failed to report the abuse.
Findings
The facility failed to report an allegation of resident abuse within 24 hours, did not accurately complete functional capacity screens, failed to include payment responsibility in negotiated service agreements, and did not ensure proper delegation and administration of medications including insulin by certified medication aides.
Deficiencies (6)
KAR 26-41-101(f)(3) Staff Treatment of Residents Reporting: Operator B failed to report an allegation of resident abuse involving resident #480 to the department within 24 hours.
KAR 26-41-201(d) Functional Capacity Screen Accurate: Operator B failed to ensure designated staff completed the functional capacity screen to accurately reflect resident #450's status at the time of screening.
KAR 26-41-202(a)(3) Negotiated Service Agreement: Operator B failed to ensure the negotiated service agreement included identification of the party responsible for payment of outside services for residents #450 and #460.
KAR 26-41-204(e) Delegation of Duties: Operator B failed to ensure a licensed nurse delegated the nursing procedure of blood sugar testing with a glucometer to certified medication aides for resident #450.
KAR 26-41-205(d) Facility Administration of Medications: Operator B failed to ensure certified staff administered resident #450's insulin according to physician's orders, including holding insulin when blood sugar was below 120.
KAR 26-41-205(d)(4) Delegation of Medication Administration: Operator B failed to ensure a licensed nurse delegated the nursing procedure of insulin pen preparation and dialing of correct insulin dose to certified medication aides for residents #450 and #491.
Report Facts
Resident census: 28
Number of residents sampled: 3
Number of closed records reviewed: 2
Insulin units: 19
Insulin units: 17
Insulin units: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator B | Named in multiple findings including failure to report abuse, ensure accurate functional capacity screening, complete negotiated service agreements, delegate nursing procedures, and ensure proper medication administration. | |
| Licensed nurse C | Interviewed regarding functional capacity screening and medication administration. | |
| Certified staff D | Certified Medication Aide | Observed administering insulin and performing blood sugar testing. |
| Administrator E | Provided documentation of investigation of abuse allegation. | |
| Licensed nurse F | Involved in resident transfer and fall documentation. | |
| Certified staff H | Assisted in resident transfer after fall. |
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 13
Date: Jan 8, 2018
Visit Reason
Health Resurvey and Complaint Investigations were conducted to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident smoking needs, incomplete baseline care plans, inadequate care plan revisions, insufficient supervision to prevent falls, inadequate nurse staffing and training, failure to post nurse staffing information, improper medication monitoring, unsanitary food handling, incomplete facility-wide assessment, and deficient infection prevention and control practices.
Deficiencies (13)
F 558 Reasonable Accommodations Needs/Preferences: The facility failed to accommodate the personal needs of assisted and independent smoking residents related to reasonable accommodations for out of the weather smoking.
F 655 Baseline Care Plan: The facility failed to complete a baseline care plan for a resident to include the need for arm protectors and foot pedals on the wheelchair.
F 657 Care Plan Timing and Revision: The facility failed to review and revise individualized care plans for two residents regarding bowel movements and fall interventions.
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision and effective interventions to prevent falls and injuries for multiple residents and failed to protect residents from potential burns from an unlocked hydrocollator.
F 726 Competent Nursing Staff: The facility failed to provide sufficient nursing staff to ensure nursing and related services to maintain resident safety and well-being.
F 730 Nurse Aide Perform Review-12 hr/yr In-Service: The facility failed to provide at least 12 hours of in-service education per year for three certified nurse aides, including training on abuse, neglect, exploitation, and dementia.
F 732 Posted Nurse Staffing Information: The facility failed to post nurse staffing information and daily census as required on all days of the survey.
F 757 Drug Regimen is Free from Unnecessary Drugs: The facility failed to monitor the need for PRN medications for lack of bowel movements for a dependent resident.
F 758 Free from Unnecessary Psychotropic Meds/PRN Use: The facility failed to provide appropriate documentation for a resident receiving PRN psychotropic medication beyond 14 days without required documentation.
F 812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to store, prepare, and serve food under sanitary conditions, including issues with freezer cleanliness, food storage, and food handling practices.
F 838 Facility Assessment: The facility failed to complete a facility-wide assessment to determine necessary resources to care for residents competently during day-to-day operations and emergencies.
F 880 Infection Prevention & Control: The facility failed to implement and maintain an infection control program, including inadequate sanitation of nebulizer components, failure to perform hand hygiene between glove changes during wound care, and inaccurate antibiotic use documentation.
F 881 Antibiotic Stewardship Program: The facility failed to develop and implement core elements of an antibiotic stewardship program to ensure effective infection prevention and control.
Report Facts
Resident census: 57
Days without bowel movement: 7
Days without bowel movement: 8
Days without bowel movement: 6
Days without bowel movement: 9
Temperature of hydrocullator water: 156
AIMS score: 0
Fall risk score: 14
Fall risk score: 20
Antibiotic treatment duration: 7
Antibiotic treatment duration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Certified Nurse Aide | Failed to complete required in-service training and improper hand hygiene during medication and aerosol treatment administration |
| Staff L | Certified Nurse Aide | Failed to complete required in-service training |
| Staff K | Certified Nurse Aide | Failed to complete required in-service training |
| Staff T | Direct Care Staff | Failed hand hygiene after perineal care for resident #204 |
| Staff AA | Direct Care Staff | Failed hand hygiene after perineal care for resident #204 |
| Staff M | Direct Care Staff | Improper cleaning of nebulizer components |
| Staff C | Administrative Staff | Failed hand hygiene between glove changes during wound care |
| Staff G | Licensed Nursing Staff | Provided information on medication and resident care |
| Staff V | Licensed Staff | Reported staffing shortage on day of inspection |
| Staff E | Licensed Staff | Reported occasional missed baths due to staffing |
| Staff B | Administrative Nursing Staff | Discussed care plan and antibiotic stewardship |
| Staff U | Administrative Staff | Discussed antibiotic use monitoring and staffing coverage |
| Staff Y | Dietary Manager | Reported on kitchen sanitation and staff illness |
| Staff X | Dietary Staff | Observed with open wound on finger and improper food handling |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 8, 2017
Visit Reason
The visit was a non-compliance revisit to the facility to determine if previous deficiencies had been corrected.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 8, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a federal revisit inspection at Lakepoint El Dorado.
Findings
All previously identified deficiencies have been corrected as of the completion date.
Deficiencies (1)
All deficiencies identified in the prior inspection have been corrected by the facility.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 8, 2017
Visit Reason
The visit was a non-compliance revisit to the facility to determine if previous deficiencies had been corrected.
Findings
The revisit resulted in a finding of no deficiency citations related to applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 9, 2017
Visit Reason
This document is a Plan of Correction submitted by LakePoint El Dorado 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, focusing on safe resident transfers and gait belt use.
Deficiencies (2)
F0000: The facility developed and implemented a system to assure correction and continued compliance with regulations. The plan includes review by the Quality Assurance/Assessment Committee by 8/25/2017.
F323-G: Resident #1 was discharged on 6/6/2017. Residents requiring assistance with transfers could be affected by unsafe transfer practices. The facility will update care plans, educate nursing staff on gait belt use, and conduct ongoing training and audits.
Report Facts
Resident discharge date: Jun 6, 2017
Compliance date: Aug 25, 2017
Number of resident transfers observed weekly: 10
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 9, 2017
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 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.
Report Facts
Denial of payment effective date: Aug 29, 2017
Termination recommendation date: Feb 9, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact person for questions regarding the letter and enforcement action |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Aug 9, 2017
Visit Reason
The inspection was conducted as a complaint investigation survey #118797 regarding the facility's failure to ensure resident safety during transfers.
Complaint Details
The complaint investigation survey #118797 was triggered by concerns about unsafe resident transfers. The resident experienced two falls, one on 5/19/17 when staff failed to use a gait belt, resulting in acute compression fractures. The resident was a high fall risk with moderate cognitive impairment and required assistance with transfers.
Findings
The facility failed to provide safe transfers for one resident, resulting in two falls and acute compression fractures of the back. Staff did not use a gait belt during transfers as required by facility policy, leading to injury.
Deficiencies (1)
483.25(d)(1)(2)(n)(1)-(3) The facility failed to ensure safe transfers for resident #1, resulting in falls and two compression fractures due to staff not using a gait belt as required.
Report Facts
Resident census: 55
Fall risk assessment score: 19
Compression fractures: 2
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 22, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the previously reported deficiencies, including those under regulation 483.60(a),(b), were corrected as of the revisit date.
Deficiencies (1)
Regulation 483.60(a),(b) deficiency was corrected as of 08/22/2016.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 10, 2016
Visit Reason
An abbreviated 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 deficiency to be at a level constituting 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, resulting in a finding of substantial compliance.
Deficiencies (1)
The most serious deficiency found constituted 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
Plan of Correction
Deficiencies: 1
Date: Aug 10, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation at the facility.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Lakepoint El Dorado complaint 08102016.
Findings
The facility reported a medication error involving resident #3 where the physician was notified, the medication dose was corrected, and relevant parties were informed. The facility outlined corrective actions including nurse in-service training, weekly audits of doctor's orders, and Quality Assurance committee reviews.
Deficiencies (1)
F425-D: Physician for resident #3 was notified of the medication error. The next dose was immediately administered and the time code was corrected to reflect twice a day. Pharmacare, DPOA, and resident were notified of the error.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 1
Date: Aug 10, 2016
Visit Reason
The inspection was conducted as a result of complaint investigations #103420 and #103720 regarding medication administration issues at the facility.
Complaint Details
The visit was triggered by complaint investigations #103420 and #103720. The complaint was substantiated as the facility failed to administer physician-ordered IV antibiotics correctly.
Findings
The facility failed to ensure that one resident received intravenous antibiotic medication as ordered by the physician. Specifically, three doses of Vancomycin were missed from 8/3/16 to 8/5/16, with staff administering only the evening doses instead of the prescribed twice daily doses.
Deficiencies (1)
F 425: The facility failed to administer intravenous Vancomycin antibiotic medication twice daily as ordered by the physician, resulting in three missed doses from 8/3/16 to 8/5/16 for a resident with MRSA and a pressure ulcer.
Report Facts
Resident census: 59
Missed medication doses: 3
Medication bags delivered: 14
Medication bags remaining: 11
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 2, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were reviewed and found to be corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 7
Date: May 3, 2016
Visit Reason
The inspection was a Health Resurvey and Complaint Investigation to evaluate compliance with regulatory requirements related to medication administration, resident rights, care planning, accident prevention, and pharmaceutical services.
Complaint Details
The inspection included a complaint investigation related to medication errors and failure to notify appropriate parties of changes in resident status or medication administration issues.
Findings
The facility failed to notify the durable power of attorney for a resident who received medication without a physician's order and failed to notify the physician when blood pressure medication was frequently held for another resident. The facility also failed to provide bathing choices, develop individualized care plans for hospice coordination, revise care plans to prevent falls, ensure accident prevention measures, and provide adequate pharmaceutical services including medication monitoring.
Deficiencies (7)
F 157: The facility failed to notify the durable power of attorney for resident #7 who received Paxil 10 mg without a physician's order for 17 days and failed to notify the physician when blood pressure medication was frequently held for resident #35.
F 242: The facility failed to provide bathing choices for resident #47 who preferred showers every other day but was not provided this preference consistently.
F 279: The facility failed to develop an individualized comprehensive care plan for resident #24 coordinating hospice care and failed to revise the care plan for resident #71 to ensure adequate fall prevention interventions.
F 280: The facility failed to review and revise the care plan for resident #71 to ensure consistent fall prevention measures including proper bed positioning and monitoring of bathroom alarms.
F 323: The facility failed to ensure preventive measures were in place for resident #71 at risk for falls, including monitoring of bathroom alarms and bed positioning.
F 425: The facility failed to follow physician's orders for resident #7, resulting in administration of Paxil 10 mg for 17 days without a physician's order.
F 428: The facility's pharmacist failed to identify irregularities in medication monitoring for resident #35, who had blood pressure medication held multiple times without physician notification.
Report Facts
Residents sampled: 19
Residents reviewed for unnecessary medications: 5
Days medication administered without order: 17
Times blood pressure medication held: 19
Times blood pressure medication held: 14
Times blood pressure medication held: 8
Resident census: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Nursing Staff | Acknowledged failure to notify DPOA and described medication administration procedures |
| Staff B | Administrative Nursing Staff | Interviewed regarding medication administration and notification |
| Staff D | Licensed Staff | Described medication aide responsibilities and physician notification process |
| Staff E | Consulting Pharmacy Staff | Reported medication error and communication with facility |
| Staff F | Direct Care Staff | Described pulse monitoring and medication holding procedures |
| Staff G | Direct Care Staff | Documented blood pressure and pulse, medication holding |
| Staff H | Licensed Nursing Staff | Reconciled medication orders and acknowledged failure to remove medication |
| Staff I | Direct Care Staff | Discussed bathing schedule and resident preferences |
| Staff J | Licensed Nursing Staff | Discussed bathing refusals and shift responsibilities |
| Staff K | Direct Care Staff | Discussed fall risk and bathroom alarm |
| Staff L | Direct Care Staff | Described hospice aide visits and supplies |
| Staff M | Licensed Nursing Staff | Discussed resident fall risk and care plan |
| Staff N | Outside Resource Licensed Nursing Staff | Described hospice supplies and visits |
| Staff O | Direct Care Staff | Discussed bed positioning for resident at fall risk |
| Staff P | Direct Care Staff | Discussed resident toileting assistance needs |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 3, 2016
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 isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance.
Deficiencies (1)
The facility had isolated 'D' level deficiencies that constitute no actual harm but have potential for more than minimal harm without immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 3, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for regulatory compliance purposes.
Findings
No deficiencies were cited in the related inspection report dated 2016-05-03.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 3, 2016
Visit Reason
The document is a Licensure Resurvey and Complaint Investigations report for the facility.
Findings
The investigations resulted in a finding of no deficiency citations for the facility.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: May 3, 2016
Visit Reason
This document is a Plan of Correction submitted by Lakepoint Nursing and Rehab Center in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies including medication errors, bathing choices, individualized care plans for hospice and fall risk residents, and medication regimen reviews. The facility outlines corrective actions and timelines to ensure compliance.
Deficiencies (7)
F157-DPOA of resident #7 was notified of a medication error where Paxil 10mg was administered without a physician’s order and additional doses were given in error. Physician of resident #35 was notified of held medication due to low pulse.
F242-LakePoint El Dorado offers bathing choices to residents, with resident #47 receiving a bath of his/her choice. Staff education and care plan updates are planned to ensure continued compliance.
F279-Resident #24 had an individualized care plan updated by the MDS Coordinator for hospice services. Hospice personnel will be involved in care plan meetings.
F280-Resident #71 had care plan updated to include fall risk interventions. The interdisciplinary team will review and update care plans and audit charts regularly.
F323-Resident #71 was evaluated by therapy and care plan updated to remove low bed. Door alarms replaced and will be upgraded and checked regularly.
F425-Resident #7 had Paxil discontinued since 03/23/16. Pharmacy consultant will review drug regimens and report discrepancies for physician intervention.
F428-Resident #35’s physician was notified of abnormal pulse. Pharmacy consultant and DON will review medication regimens and ensure timely follow-up.
Inspection Report
Life Safety
Deficiencies: 1
Date: Jan 12, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at an "F" level, indicating no harm with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for deficiencies at an "F" level under the Life Safety Code survey, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Apr 12, 2016
Effective date for provider agreement termination: Jul 12, 2016
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter and coordinated survey results |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution requests |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 11, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the deficiency identified under regulation 483.30(a) was corrected as of 09/11/2015. No other deficiencies were noted in this report.
Deficiencies (1)
Regulation 483.30(a) deficiency was corrected as of 09/11/2015.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 11, 2015
Visit Reason
This document is a plan of correction submitted by the facility in response to cited deficiencies from a complaint investigation.
Findings
The facility was cited for insufficient 24-hour nursing staff per care plans, specifically regarding timeliness of answering call lights promptly.
Deficiencies (1)
F353 483.30(a) insufficient 24-hour nursing staff per care plans. The facility will conduct staff in-service training and review care plans to ensure appropriate staff allocation and timely response to call lights.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for plan of correction assistance | |
| Lana Pohlman | Administrator | Submitted the plan of correction |
| Irina Strakhova | Added and modified the plan of correction |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Aug 21, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#90367) regarding the facility's nursing staff response to resident call lights.
Complaint Details
The complaint investigation #90367 found substantiated issues with delayed nursing staff response to call lights, specifically for resident #01 who waited over 30 minutes for toileting assistance.
Findings
The facility failed to respond timely to a resident's call light for toileting assistance, resulting in a delay of over 30 minutes. Additional residents reported slow staff response to call lights.
Deficiencies (1)
483.30(a) The facility failed to provide sufficient 24-hour nursing staff to promptly respond to resident call lights, resulting in a resident waiting over 30 minutes for toileting assistance.
Report Facts
Resident census: 78
Call light delay duration: 36
Call light pager delay: 90
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 21, 2015
Visit Reason
An abbreviated 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 a 'D' 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 and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 12, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.25(a)(3), 483.25(h), 483.35(i), 483.60(b),(d),(e), and 483.65 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Feb 12, 2015
Visit Reason
This document is a Plan of Correction submitted by LakePoint Nursing & Rehab Center of El Dorado to address deficiencies cited during a prior survey.
Findings
The facility developed and implemented a system to assure correction and ongoing compliance with cited deficiencies related to resident assistance, transfer techniques, dietary sanitation, medication management, infection control, and dishwashing procedures.
Deficiencies (6)
F312-D: The facility will conduct in-service training on resident ADL assistance and perform routine observations and follow-up training to ensure proper care.
F323-D: Therapy staff will identify residents needing transfer assistance and provide training on safe transfer techniques with ongoing observation and reporting.
F371-F: Dietary staff will review and sign policy on safe dishwashing; all listed items will be repaired, cleaned, or replaced with ongoing staff training and monitoring.
F431-E: Licensed staff and medication aides will review medication dating and destruction policies; reconciliation systems and random compliance checks will be implemented.
F441-E: Environmental staff will attend infection control training and be observed for compliance with disease prevention procedures including hand washing and glove use.
S0600-F: Dietary staff will attend in-service on dishwashing procedures; items will be repaired or replaced; the facility will seek a full-time Certified Dietary Manager.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Feb 12, 2015
Visit Reason
This is a follow-up revisit inspection to verify that previously reported deficiencies have been corrected.
Findings
The report documents that the previously cited deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected as of 2015-02-12.
Inspection Report
Re-Inspection
Census: 69
Deficiencies: 1
Date: Jan 15, 2015
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to employ a full-time certified dietary manager to oversee the dietary department. Observations revealed sanitation issues in the kitchen including debris on flour and sugar bin lids, water held between stacked pans, residue on utensils, and worn surfaces in the dining area.
Deficiencies (1)
28-39-158(a) Dietary services. The facility failed to employ a full-time certified dietary manager to oversee the dietary department. Kitchen observations found debris on flour and sugar bin lids, water between stacked pans, residue on utensils, and worn surfaces in the dining area.
Report Facts
Resident census: 69
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 15, 2015
Visit Reason
The Health Licensure Resurvey was conducted to assess the facility's compliance with health licensure requirements.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Enforcement
Deficiencies: 1
Date: Jan 15, 2015
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 February 12, 2015.
Deficiencies (1)
The facility had 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 10, 2014
Visit Reason
A Life Safety Code survey was conducted 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. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for isolated 'D' level deficiencies indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Oct 10, 2014
Provider agreement termination date: Jan 10, 2015
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Oct 16, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report confirms that all previously identified deficiencies listed on the CMS-2567 have been corrected by the revisit date of 10/16/2013.
Deficiencies (4)
Regulation 483.10(b)(5)-(10), 483.10(b)(1): Previously cited deficiencies have been corrected as of 10/16/2013.
Regulation 483.35(d)(1)-(2): Previously cited deficiencies have been corrected as of 10/16/2013.
Regulation 483.35(i): Previously cited deficiencies have been corrected as of 10/16/2013.
Regulation 483.65: Previously cited deficiencies have been corrected as of 10/16/2013.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 4
Date: Oct 2, 2013
Visit Reason
The inspection was conducted as a health resurvey and complaint investigation involving multiple complaint numbers (#67812, #68272, #67875, #68938, and #67618).
Complaint Details
The inspection was triggered by multiple complaints (#67812, #68272, #67875, #68938, and #67618). The complaint investigation found substantiated deficiencies related to resident rights, food service, sanitation, and infection control.
Findings
The facility failed to post state ombudsman information, resulting in residents and family lacking knowledge of the ombudsman program. Food was served at improper temperatures and was often cold. The kitchen failed to maintain sanitary conditions, including improper food storage and unclean equipment. The facility also failed to maintain a consistent infection control program, including incomplete infection logs and lack of staff in-service training.
Deficiencies (4)
F156: The facility failed to post the state ombudsman information and phone number, and residents lacked knowledge of the ombudsman program.
F364: The facility failed to serve food at proper temperatures, with multiple residents reporting cold meals and observations confirming temperatures below required levels.
F371: The facility failed to store, prepare, distribute, and serve food under sanitary conditions, including unclean utensils, dirty equipment, improper food labeling, and inadequate sanitizing solutions.
F441: The facility failed to maintain a consistent infection control program, including incomplete infection logs and lack of infection surveillance and staff training.
Report Facts
Census: 70
Food temperature: 115
Food temperature: 124
Food temperature: 132
Sanitizing solution concentration: 100
Expired dairy product days: 6
Infections reported: 3
Inspection Report
Original Licensing
Deficiencies: 0
Date: Oct 2, 2013
Visit Reason
The licensure survey was conducted to assess compliance for the facility's licensing requirements.
Findings
The survey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Sep 24, 2013
Visit Reason
This document is a Plan of Correction submitted by LakePoint Nursing Center in response to deficiencies cited during a health facility resurvey.
Findings
The facility identified multiple deficiencies related to resident notice, meal service, kitchen sanitation, and infection control. Corrective actions include staff inservices, equipment cleaning and replacement, and monitoring by the Administrator and Certified Dietary Manager.
Deficiencies (4)
F156-B: The facility failed to ensure residents and families received written notice upon admission and periodically during their stay. The facility corrected this by replacing the Ombudsman poster and ensuring contact information visibility.
F364-F: The facility did not consistently serve meals at the temperature ordered by residents. Dietary staff were inserviced on steam table operation and food temperature maintenance to ensure compliance.
F371-F: Multiple kitchen sanitation issues were identified including unlabeled open dates, improper refrigerator temperature, unclean equipment, and unsanitary utensils. The facility discarded or cleaned items and inserviced staff on proper procedures.
F441-F: The facility failed to maintain a consistent infection control program, specifically regarding the use of an administrative log. The Infection Control Coordinator will continue surveillance and monitoring.
Report Facts
Dates of corrective actions: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Submitted the Plan of Correction and responsible for monitoring compliance |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Added and modified the Plan of Correction document |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 6, 2012
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jun 19, 2012
Visit Reason
This document is a Plan of Correction submitted by LakePoint Nursing Center in response to deficiencies cited during a health facility resurvey and complaint investigations.
Findings
The facility developed and implemented corrective actions addressing bathing preferences, nutritional programs, hydration, orthostatic blood pressure monitoring for psychoactive medications, dental treatment, and pharmacist monitoring of medications with Black Box Warnings.
Deficiencies (6)
F246 LakePoint Nursing Center will provide reasonable accommodation of individual bathing preferences, including offering showers instead of bed baths unless medically contraindicated.
F325 LakePoint Nursing Center will consistently provide nutritional programs to assist dependent residents in maintaining weight and nutritional status, including timely physician notification of significant weight changes.
F327 LakePoint Nursing Center will ensure residents unable to obtain fluids independently have free access to fluids per their preference and receive thickened liquids as ordered.
F329 LakePoint Nursing Center will develop and implement a system to monitor orthostatic blood pressures on residents taking psychoactive medications with Black Box Warnings and monitor behavior for those on psychotropic medications.
F412 LakePoint Nursing Center will provide appropriate dental treatment and services to enable each resident's eating ability, including emergency and routine dental services covered under the State plan.
F428 LakePoint Nursing Center's consultant pharmacist will identify and notify the facility of monitoring requirements for psychoactive medications with Black Box Warnings to ensure resident safety and behavior monitoring.
Report Facts
Date of quality improvement committee review: Jun 22, 2012
Date of plan of correction completion: Jul 6, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 6
Date: Jun 18, 2012
Visit Reason
The inspection was conducted as a health facility resurvey and investigation of complaints #57603 and #57167.
Complaint Details
The inspection was triggered by complaints #57603 and #57167.
Findings
The facility was found deficient in accommodating resident bathing preferences, maintaining nutritional status, providing sufficient hydration, ensuring drug regimen safety, and providing appropriate dental services. Specific failures included lack of shower equipment for a resident, inadequate nutritional intake and monitoring for multiple residents, insufficient hydration for dependent residents, failure to monitor psychoactive medication effects, and failure to provide dental care for a resident with broken teeth.
Deficiencies (6)
F246: The facility failed to provide one resident (#11) with equipment necessary to receive a shower, not accommodating individual bathing preferences.
F325: The facility failed to ensure 3 residents (#15, #45, #73) received adequate nutritional intake to prevent weight loss and failed to provide planned nutritional interventions.
F327: The facility failed to provide adequate hydration for 2 residents (#11 and #76), including failure to offer fluids routinely and maintain access to fluids.
F329: The facility failed to monitor 2 residents (#15 and #69) receiving psychoactive medications for behavior and orthostatic hypotension as recommended by black box warnings.
F412: The facility failed to provide appropriate dental services to resident #7 with broken natural teeth to maintain or improve eating ability.
F428: The facility's consulting pharmacist failed to identify lack of monitoring for adverse effects of psychoactive medications for residents #15 and #69, including behavior monitoring and orthostatic hypotension assessment.
Report Facts
Resident census: 81
Residents selected for review: 22
Weight loss percentage: 11.46
Weight loss percentage: 9.09
Weight loss percentage: 13.4
Fluid intake requirement: 2000
Latuda dosage: 40
Ativan dosage: 0.25
Geodon dosage: 20
Risperdal dosage: 0.5
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N008002 POC 74DD11
Visit Reason
This document is a Plan of Correction submitted by LakePoint El Dorado 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, specifically addressing safe resident transfers and care plan updates.
Deficiencies (2)
F0000: The facility developed and implemented a system to assure correction and continued compliance with regulations. The statement of deficiency will be reviewed by the Quality Assurance/Assessment Committee by 6/26/19.
F689-D: Resident #01 was admitted to the hospital and returned to the community. The facility will review and update care plans for residents requiring transfer assistance and provide nursing staff education and training on safe transfers by specified dates.
Report Facts
Compliance date: Jul 5, 2019
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008002 POC G7SO11
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility Lakepoint El Dorado ALF.
Findings
No specific deficiencies or findings are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008002 POC HCG511
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility Lakepoint El Dorado ALF.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008002 POC K0VS11
Visit Reason
This document is a plan of correction related to a prior deficiency report for the facility.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the plan of correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008002 POC K0VS12
Visit Reason
This document is a Plan of Correction related to a previous inspection or regulatory finding for the facility identified by State ID N008002 and Event ID K0VS12.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N008002 POC N7GT11
Visit Reason
This document serves as a Plan of Correction related to a prior inspection event identified by Event ID N7GT11.
Findings
No deficiencies or findings are detailed in this document. It only references the Plan of Correction status and contact information for assistance.
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