Inspection Reports for Lakepoint El Dorado LLC
1313 S HIGH STREET, EL DORADO, KS, 67042-3751
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 14, 2020 found no deficiencies and confirmed the facility was in compliance with all regulations surveyed. Prior inspections showed a pattern of deficiencies mainly related to resident care, medication management, infection control, and facility maintenance, including issues with respiratory care, medication administration errors, and unsanitary food and linen handling. Complaint investigations mostly resulted in unsubstantiated findings, though some substantiated cases involved inadequate assistance during resident transfers leading to falls and medication administration errors. Enforcement actions such as denial of payment for new Medicare and Medicaid admissions were noted in 2017 due to deficiencies causing actual harm but not immediate jeopardy; fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with repeated revisits confirming correction of cited deficiencies and the most recent inspection showing full compliance.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
147% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
57 residents
Based on a December 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 10
Date: Dec 12, 2019
Visit Reason
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.
Findings
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.
Deficiencies (10)
Failure to provide evidence of bed hold notification when resident transferred to hospital.
Failure to provide personal care including shaving for a dependent resident.
Failure to provide necessary respiratory care including nebulizer treatments and proper storage and cleaning of respiratory equipment.
Failure to administer medications as ordered and failure to reorder medications timely.
Pharmacist failed to identify and report irregularities related to failure to obtain ordered annual lab tests.
Failure to ensure resident's drug regimen was free from unnecessary drugs due to lack of monitoring lab work.
Failure to provide sanitary food storage; undated and expired food items found in resident refrigerator.
Failure to handle, store, and process linens to prevent cross contamination and spread of infection; soiled linens found on floor and unsanitizable storage surfaces.
Failure to provide annual education and vaccines for influenza and pneumococcal disease to residents and/or representatives.
Failure to provide maintenance services to ensure a safe, functional, sanitary, and comfortable environment in laundry area.
Report Facts
Residents reviewed for bed hold notification: 15
Residents reviewed for ADL care: 3
Residents reviewed for respiratory care: 2
Residents reviewed for medication administration: 5
Residents reviewed for unnecessary medications: 5
Residents reviewed for influenza and pneumococcal vaccines: 5
Residents on east wing: 28
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Reported failure to provide bed hold notification and respiratory care deficiencies |
| Administrative Nurse D | Administrative Nurse | Verified multiple deficiencies including medication administration, infection control, and vaccine education |
| Licensed Nurse K | Licensed Nurse | Verified failure to obtain ordered lab work for resident |
| Licensed Nurse L | Licensed Nurse | Verified failure to obtain ordered lab work and vaccine education |
| Certified Medication Aide M | Certified Medication Aide | Observed failure to properly administer nebulizer treatment |
| Housekeeping Staff W | Housekeeping Staff | Verified laundry maintenance deficiencies |
| Maintenance Staff V | Maintenance Staff | Verified laundry maintenance deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 9
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 survey conducted on 12/03/2019.
Findings
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.
Deficiencies (9)
Bed hold policy not properly communicated and documented during resident hospital transfers.
Resident shaving frequency preferences not consistently obtained or monitored.
Respiratory equipment storage and maintenance issues.
Medication room and medication cart audits not consistently performed.
Routine lab orders not consistently audited and monitored.
Medication room refrigerator contained old and outdated food without proper labeling and dating.
Soiled linen barrels uncovered and improper handling of soiled linens.
Influenza and pneumococcal vaccination procedures needing improved education and audit.
Laundry room maintenance issues including baseboard repair, painting, and ceiling vent replacement.
Report Facts
Compliance date: Jan 10, 2020
Inspection date: Dec 3, 2019
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 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.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Jun 5, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#141115) to evaluate the facility's compliance with accident hazard prevention and resident supervision requirements.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to provide adequate planned assistance with transfers/walking for one resident to prevent further falls.
Report Facts
Census: 81
Sample size: 3
Resident BIMS score: 12
Fall incidents: 1
Inspection Report
Annual Inspection
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 investigated, KS00135564 and KS00136009, were both found to be unsubstantiated.
Complaint Details
Complaints KS00135564 and KS00136009 were investigated and found to be unsubstantiated.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B. Both complaints investigated were unsubstantiated.
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).
Complaint Details
Complaints KS00135564 and KS00136009 were investigated and found to be unsubstantiated.
Findings
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 21, 2018
Visit Reason
The visit was conducted as a complaint investigation (#130418) at 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, requirements 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) at 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, requirements 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 #130418 for the facility Lakepointe El Dorado.
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, requirements for long term care facilities.
Deficiencies (1)
No deficiency citation found in complaint investigation #130418.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 23, 2018
Visit Reason
A revisit survey was conducted on 3/23/2018 for all previous deficiencies cited on 1/8/2018.
Findings
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.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 23, 2018
Visit Reason
A revisit survey was conducted on 3/23/2018 for all previous deficiencies cited on 1/8/2018.
Findings
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.
Deficiencies (1)
All previous deficiencies cited on 1/8/2018 have been corrected.
Report Facts
Compliance date: Feb 7, 2018
Inspection Report
Re-Inspection
Deficiencies: 6
Date: Feb 21, 2018
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
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.
Deficiencies (6)
Deficiency related to regulation 26-41-101 (f)(3)
Deficiency related to regulation 26-41-201 (d)
Deficiency related to regulation 26-41-202 (a)
Deficiency related to regulation 26-41-204 (e)
Deficiency related to regulation 26-41-205 (d)(1-2)
Deficiency related to regulation 26-41-205 (d)(4)
Report Facts
Deficiencies corrected: 6
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 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.
Findings
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.
Deficiencies (6)
Failure to report an allegation of resident abuse involving resident #480 to the department within 24 hours.
Failure to ensure designated staff completed the functional capacity screen accurately for resident #450.
Failure to include identification of each party responsible for payment of outside services in the negotiated service agreement for residents #450 and #460.
Failure to ensure a licensed nurse delegated the nursing procedure of blood sugar testing with a glucometer to medication aides.
Failure to ensure certified staff administered resident #450's insulin as ordered by the physician, including holding insulin when blood sugar was below 120.
Failure 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
Census: 28
Residents sampled: 3
Closed records reviewed: 2
Insulin units: 19
Insulin units: 17
Insulin units: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator B | Failed to report abuse allegation, failed to ensure accurate functional capacity screening, failed to ensure completion of negotiated service agreements, failed to ensure proper delegation of nursing procedures, and failed to ensure medication administration compliance. | |
| Administrator E | Completed grievance/complaint report and investigation related to resident #480 abuse allegation. | |
| Licensed nurse C | Licensed Nurse | Documented resident care, reported deficiencies in functional capacity screening, and explained medication administration requirements. |
| Licensed nurse F | Licensed Nurse | Involved in care and transfer of resident #480 during fall incidents. |
| Certified staff H | Certified Staff | Assisted in transferring resident #480 after fall. |
| Certified staff D | Certified Medication Aide | Performed blood sugar testing and insulin administration for resident #450. |
| Certified medication aide J | Certified Medication Aide | Lacked documented licensed nurse delegation for blood sugar testing and insulin pen preparation. |
| Certified medication aide K | Certified Medication Aide | Lacked documented licensed nurse delegation for blood sugar testing and insulin pen preparation. |
| Certified medication aide L | Certified Medication Aide | Lacked documented licensed nurse delegation for insulin pen preparation. |
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Jan 8, 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 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.
Deficiencies (14)
Facility-wide system developed to assure correction and continued compliance with regulations.
Residents instructed to use covered area for smoking during bad weather.
Baseline care plans reviewed and interventions ensured including sleeve protectors and foot pedals.
Care plans reviewed/revised for residents with falls and constipation with appropriate interventions.
Care plans audited and revised for residents at risk for falls; Hydrocollator locked and removed.
Staffing patterns reviewed to ensure appropriate supervision.
QAPI plan initiated; staff educated on Abuse, Neglect and Exploitation.
Staff educated on protocol for posting staffing information.
Medication regimen reviewed for residents with constipation; interventions ensured.
PRN psychotropic medication orders reviewed and discontinued as appropriate; staff education planned.
Dietary sanitation improved with new thermometer, cleaning schedules, and monitoring.
Facility assessment started and to be completed by administrator.
Nebulizer components replaced; infection control log corrected; antibiotic documentation and hand hygiene competencies planned.
Antibiotic Stewardship program reviewed and core elements ensured; staff education planned.
Report Facts
Compliance date: 2018
Audit frequency: 4
Staff interviews: 5
Medication review frequency: 5
Storage duration: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christie Underwood | Administrator | Submitted the Plan of Correction; involved in review and education activities |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Census: 57
Deficiencies: 13
Date: Jan 8, 2018
Visit Reason
The inspection was a Health Resurvey and Complaint Investigations for multiple complaint numbers.
Findings
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.
Deficiencies (13)
Failure to accommodate personal needs of smoking residents related to reasonable accommodations for out of the weather smoking.
Failure to complete baseline care plan to include resident's need for arm protectors and foot pedals on wheelchair.
Failure to review and revise individualized care plans for residents regarding bowel movements and fall interventions.
Failure to provide adequate supervision and/or develop and implement effective interventions to prevent falls resulting in injuries and failure to protect residents from potential burns from unlocked hydrocollator.
Failure to provide sufficient nursing staff to ensure nursing and related services to attain or maintain the highest physical, mental and psychosocial well being of residents.
Failure to provide no less than 12 hours of in-service education per year for some certified nurse aides.
Failure to post nurse staffing information or daily census as required on 5 out of 5 days of the survey.
Failure to monitor the need for PRN medications for lack of bowel movements.
Failure to provide appropriate documentation for unnecessary PRN psychotropic medications beyond 14 days.
Failure to store, prepare, distribute and serve food under sanitary conditions.
Failure to complete a facility-wide assessment to determine resources necessary to care for residents competently during day-to-day operations and emergencies.
Failure to implement, monitor and maintain an infection control program including proper hand hygiene, cleaning of nebulizer equipment, and accurate antibiotic use documentation.
Failure to develop and implement the core elements of an antibiotic stewardship program.
Report Facts
Residents sampled: 21
Residents with smoking status: 6
Days without bowel movements: 9
Temperature of hydrocullator water: 156
Number of days nurse staffing info not posted: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Certified Nurse Aide | Failed to complete required in-service training and failed to perform hand hygiene and gloving properly during medication and nebulizer treatment |
| 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 to perform hand hygiene after perineal care |
| Staff AA | Direct Care Staff | Failed to perform hand hygiene after perineal care |
| Staff M | Direct Care Staff | Failed to properly clean nebulizer components |
| Staff C | Administrative Staff | Failed to perform hand hygiene between glove changes during wound dressing change |
| Staff G | Licensed Nursing Staff | Discussed resident medication and care plans |
| Staff V | Licensed Staff | Reported staffing shortages on day of inspection |
| Staff E | Administrative Staff | Responsible for staffing coverage and monitoring antibiotic use |
| Staff B | Administrative Nursing Staff | Discussed care plan revisions and antibiotic stewardship implementation |
| Staff Y | Dietary Manager | Supervised kitchen and dietary staff, noted sanitation issues |
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 the Lakepoint El Dorado federal revisit inspection on 2017-09-08.
Findings
All deficiencies identified in the prior inspection were corrected as of 2017-09-08.
Deficiencies (1)
All deficiencies corrected
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
Complaint Investigation
Census: 55
Deficiencies: 1
Date: Aug 9, 2017
Visit Reason
The inspection was conducted as a complaint investigation survey #118797 to evaluate the facility's compliance with accident hazard prevention and resident supervision requirements.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure the resident environment was free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents, specifically failure to use a gait belt during resident transfers.
Report Facts
Resident census: 55
Residents sampled: 3
Fall risk assessment score: 19
Compression fractures: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Reported failing to use a gait belt during resident transfer leading to fall | |
| Direct care staff B | Reported resident's rapid decline and use of gait belt with assistance | |
| Licensed nursing staff D | Licensed nursing staff | Reported facility policy requiring gait belt use during transfers and resident's fall risk |
| Physician office staff E | Reported follow-up visit and MRI findings of new compression fractures |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 9, 2017
Visit Reason
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.
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, including denial of payment for new Medicare and Medicaid admissions effective August 29, 2017.
Deficiencies (1)
Deficiencies found at a level of actual harm that is not immediate jeopardy requiring corrections
Report Facts
Denial of payment effective date: Aug 29, 2017
Timeframe for substantial compliance: 6
Termination recommendation date: Feb 9, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure, Certification & Enforcement Manager | Contact for questions regarding the letter and enforcement action |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 6, 2017
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited during a prior survey of LakePoint El Dorado facility.
Findings
The facility developed and implemented a system to assure correction and continued compliance with regulations, specifically addressing safe resident transfers and gait belt use.
Deficiencies (1)
Deficiency related to safe transfers and gait belt use for residents requiring assistance.
Report Facts
Compliance completion date: Aug 25, 2017
Resident discharge date: Jun 6, 2017
Number of resident transfers observed: 10
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 22, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that the previously cited deficiencies, including those under regulation 483.60(a),(b), were corrected as of the revisit date.
Deficiencies (1)
Deficiency related to regulation 483.60(a),(b)
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to administer intravenous antibiotic medication as ordered by the physician, resulting in missed doses for resident #3.
Report Facts
Resident census: 59
Sampled residents: 3
Missed medication doses: 3
Vancomycin bags delivered: 14
Vancomycin bags remaining: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Administrative Nursing Staff | Verified failure to change medication order and failure to administer AM doses. |
| Staff B | Administrative Nursing Staff | Called physician regarding medication order and lab testing after notification of missed doses. |
| Staff D | Licensed Nursing Staff | Reported unawareness of resident's physician orders and failure to administer IV medications. |
| Staff E | Licensed Nursing Staff | Reported unawareness of resident's physician orders and failure to administer IV medications. |
| Consultant Staff GG | Reported potential for adverse reactions due to missed antibiotic doses but did not believe harm occurred. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 10, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation related to a medication error at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Medication error involving incorrect time code for medication administration affecting resident #3.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christie Underwood | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 10, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious 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.
Deficiencies (1)
Deficiency level deficiency that constitutes 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 the contact person regarding the survey findings and plan of correction |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Jun 2, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers were corrected as of the revisit date, with completion dates noted as 06/02/2016.
Deficiencies (7)
Deficiency related to regulation 483.10(b)(11)
Deficiency related to regulation 483.15(b)
Deficiency related to regulations 483.20(d), 483.20(k)(1)
Deficiency related to regulations 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.25(h)
Deficiency related to regulations 483.60(a),(b)
Deficiency related to regulation 483.60(c)
Report Facts
Deficiencies corrected: 7
Inspection Report
Health Resurvey And Complaint Investigation
Census: 65
Deficiencies: 8
Date: May 3, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #97759 to assess compliance with regulatory requirements.
Complaint Details
The inspection included a complaint investigation as indicated by the report referencing Complaint Investigation #97759.
Findings
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.
Deficiencies (8)
Failed to notify the durable power of attorney (DPOA) and physician when resident #7 received medication Paxil 10 mg without a physician's order for 17 days.
Failed to notify the physician when blood pressure medication Carvedilol was frequently held for resident #35 due to low pulse.
Failed to provide bathing choices for resident #47, not honoring the resident's preference for showering every other day.
Failed to develop an individualized comprehensive care plan for resident #24 coordinating hospice care and specifying actual care and supplies provided by hospice and facility.
Failed to review and revise the care plan for resident #71 to ensure adequate preventive measures for fall risk, including inconsistent bed positioning and ineffective bathroom alarm.
Failed to ensure the resident environment was free of accident hazards and provide adequate supervision and assistance devices for resident #71 at risk for falls.
Failed to provide pharmaceutical services ensuring accurate medication administration for resident #7, resulting in administration of Paxil 10 mg without physician order for 17 days.
Failed to provide adequate medication monitoring by the pharmacist for resident #35, not identifying irregularities in holding blood pressure medication as ordered.
Report Facts
Census: 65
Residents sampled: 19
Residents reviewed for unnecessary medications: 5
Days medication administered without order: 17
Times Carvedilol held in February 2016: 19
Times Carvedilol held in March 2016: 14
Times Carvedilol held in April 2016: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrative Nursing Staff | Acknowledged failure to notify DPOA of medication error for resident #7 and provided clarification order for Carvedilol |
| Staff B | Administrative Nursing Staff | Interviewed regarding medication error for resident #7 |
| Staff D | Licensed Staff | Described medication aide responsibilities for pulse checks and physician notification for resident #35 |
| Staff E | Consulting Pharmacy Staff | Reported medication error for resident #7 and communication with facility |
| Staff F | Direct Care Staff | Described pulse monitoring and medication holding for resident #35 |
| Staff G | Direct Care Staff | Described pulse and blood pressure documentation and medication holding for resident #35 |
| Staff H | Licensed Nursing Staff | Reconciled readmission orders for resident #7 and acknowledged medication error |
| Staff I | Direct Care Staff | Discussed bathing schedule and resident preferences for resident #47 |
| Staff J | Licensed Nursing Staff | Discussed bathing refusals and staff responsibilities |
| Staff L | Direct Care Staff | Described hospice aide visits and supplies for resident #24 |
| Staff M | Licensed Nursing Staff | Discussed fall risk and toileting assistance for resident #71 |
| Staff N | Outside Resource Licensed Nursing Staff | Described hospice supplies and visits for resident #24 |
| Staff O | Direct Care Staff | Discussed bed positioning for resident #71 |
| Staff P | Direct Care Staff | Discussed toileting assistance for resident #71 |
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 the facility identified as ASPEN Event ID K1JC11.
Findings
No deficiencies were cited in the related inspection report dated 05/03/2016.
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 El Dorado in response to deficiencies cited during a prior inspection on 05/03/2016.
Findings
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.
Deficiencies (7)
Medication error where resident #7 received Paxil 10mg without a physician’s order and additional doses after discontinuation.
Bathing choices not consistently offered to resident #47.
Individualized care plan for resident #24 receiving Hospice services not updated.
Care plan for resident #71 at risk for falls not updated with appropriate interventions.
Care plan and environmental interventions for resident #71 who has fallen not fully implemented.
Order for Paxil discontinued for resident #7 since 03/23/16 but medication errors occurred.
Physician of resident #35 notified of abnormal pulse on 04/27/16; medication holding procedures require improvement.
Report Facts
Dates for corrective actions: May 13, 2016
Dates for corrective actions: May 16, 2016
Dates for corrective actions: May 20, 2016
Dates for corrective actions: May 25, 2016
Dates for corrective actions: May 19, 2016
Dates for corrective actions: Jun 2, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanapohlman | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 3, 2016
Visit Reason
The visit was a Licensure Resurvey and Complaint Investigations #94114 and #93655 of the facility.
Complaint Details
Complaint Investigations #94114 and #93655 were conducted and found no deficiencies.
Findings
The investigations resulted in a finding of no deficiency citations.
Inspection Report
Deficiencies: 1
Date: May 3, 2016
Visit Reason
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.
Findings
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.
Deficiencies (1)
Isolated 'D' level deficiencies constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Named as contact and signatory related to the survey findings and plan of correction acceptance. |
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 if the facility was in 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 '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.
Deficiencies (1)
Deficiencies cited at 'F' level with no harm but potential for more than minimal harm, not immediate jeopardy.
Report Facts
Effective date for denial of payments: Apr 12, 2016
Provider agreement termination date: Jul 12, 2016
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter and coordinated the survey results. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for informal dispute resolution process. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 11, 2015
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation.
Complaint Details
This Plan of Correction is related to a complaint investigation identified by Event ID K9FX11 and Complaint ID 082115.
Findings
The facility was cited for insufficient 24-hour nursing staff per care plans, specifically regarding timeliness of answering call lights promptly.
Deficiencies (1)
Insufficient 24-hour nursing staff per care plans, including delays in answering call lights promptly.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Lana Pohlman | Administrator | Submitted the Plan of Correction. |
| Irina Strakhova | Added and modified the Plan of Correction. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 11, 2015
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency identified under regulation 483.30(a) with ID Prefix F0353
Report Facts
Deficiencies corrected: 1
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Aug 21, 2015
Visit Reason
The inspection was conducted as a complaint investigation (#90367) regarding concerns about the facility's nursing staff response to resident call lights.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failed to answer a call light promptly to provide toileting assistance to one resident.
Report Facts
Resident census: 78
Call light delay duration (minutes): 36
Number of sampled residents: 3
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Aug 21, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be a '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.
Deficiencies (1)
Most serious deficiency found was a 'D' level deficiency constituting 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 person regarding 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 cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that all previously reported deficiencies identified by their regulation numbers and prefix codes were corrected as of 02/12/2015.
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Feb 12, 2015
Visit Reason
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.
Findings
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.
Deficiencies (1)
Deficiency under regulation 28-39-158(a) previously cited and corrected.
Inspection Report
Enforcement
Deficiencies: 1
Date: Jan 15, 2015
Visit Reason
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.
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)
Deficiencies cited at 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date of substantial compliance: Feb 12, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Census: 69
Deficiencies: 8
Date: Jan 15, 2015
Visit Reason
The inspection was conducted as 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 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.
Deficiencies (8)
Failure to employ a full-time certified dietary manager to oversee the dietary department.
Flour and sugar bins lids contained debris particles and a sticky substance.
Seven large baking pans stacked on top of each other held water between them.
Three large muffin pans in the clean utensil area had build-up of cooking spray residue and food particles.
Five steam table food pans stacked on top of each other held water between them.
Fourteen green coffee mugs had stain build-up and scratches on the interior.
Beverage/snack area cabinet and cupboard doors had worn varnish exposing wood surfaces.
Three dish drying bins had cracks and scraped areas making sanitation difficult.
Report Facts
Census: 69
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 15, 2015
Visit Reason
The Health Licensure Resurvey was conducted as a renewal inspection of the facility.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Life Safety
Deficiencies: 1
Date: Jul 10, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found isolated 'D' level deficiencies with no harm but potential for more than minimal harm 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.
Deficiencies (1)
Isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Oct 10, 2014
Provider agreement termination date: Jan 10, 2015
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Warner Harrison | Administrator | Facility administrator named in the report header. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
| Joe Ewert | Commissioner | Mentioned in carbon copy (c:). |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Oct 16, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2013-10-02.
Findings
The report shows that all previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of 2013-10-16.
Deficiencies (4)
Deficiency related to regulation 483.10(b)(5) - (10), 483.10(b)(1)
Deficiency related to regulation 483.35(d)(1)-(2)
Deficiency related to regulation 483.35(i)
Deficiency related to regulation 483.65
Report Facts
Deficiencies corrected: 4
Original survey date: Oct 2, 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 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.
Findings
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.
Deficiencies (4)
Failure to post the state ombudsman information and phone number, resulting in residents and family lacking knowledge of the ombudsman program.
Failure to serve palatable food at proper temperatures to residents, with multiple residents reporting food served cold and observations confirming food temperatures below required levels.
Failure to store, prepare, distribute, and serve food under sanitary conditions, including issues with refrigerator temperatures, expired/open dates on food items, dirty kitchen equipment, and inadequate sanitizing solutions.
Failure to maintain an effective infection control program, including inconsistent infection surveillance logs and lack of timely in-service education for staff.
Report Facts
Census: 70
Food temperature: 115
Food temperature: 124
Food temperature: 132
Sanitizing solution concentration: 100
Open date violation: 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 for the facility.
Inspection Report
Follow-Up
Deficiencies: 6
Date: Jul 6, 2012
Visit Reason
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.
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.
Deficiencies (6)
Deficiency related to regulation 483.15(e)(1)
Deficiency related to regulation 483.25(i)
Deficiency related to regulation 483.25(j)
Deficiency related to regulation 483.25(l)
Deficiency related to regulation 483.55(b)
Deficiency related to regulation 483.60(c)
Report Facts
Deficiencies corrected: 6
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 (#1455) and investigations of complaints (#57603 and #57167).
Complaint Details
The Plan of Correction addresses deficiencies cited from investigations of complaints #57603 and #57167.
Findings
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.
Deficiencies (6)
Failure to accommodate individual bathing preferences, specifically shower versus bed bath.
Inconsistent provision and implementation of nutritional programs for dependent residents.
Failure to ensure residents unable to obtain fluids independently have free access to fluids and appropriate thickened liquids.
Lack of system to monitor orthostatic blood pressures on residents taking psychoactive medications with Black Box Warnings.
Failure to provide appropriate dental treatment and services to enable residents' eating ability.
Failure to identify and notify monitoring requirements for adverse effects of psychoactive medications with Black Box Warnings.
Report Facts
Dates of corrective actions: Corrective actions and trainings were completed or scheduled between 06/19/2012 and 07/06/2012.
Weight loss monitoring thresholds: 5
Weight loss monitoring thresholds: 7.5
Weight loss monitoring thresholds: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 5
Date: Jun 18, 2012
Visit Reason
The health facility resurvey and investigation of complaints #57603 and #57167.
Complaint Details
Investigation of complaints #57603 and #57167.
Findings
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.
Deficiencies (5)
Failed to provide one resident reasonable accommodation of individual bathing preferences by failure to provide equipment necessary for shower.
Failed to ensure 3 residents received adequate nutritional intake to prevent weight loss.
Failed to provide sufficient fluid intake to maintain proper hydration for 2 residents.
Resident's drug regimen not free from unnecessary drugs; failed to monitor residents receiving psychoactive medications for behaviors and orthostatic hypotension.
Failed to provide or obtain routine and emergency dental services to meet resident needs related to broken natural teeth.
Report Facts
Resident census: 81
Residents selected for review: 22
Resident #45 weight loss: 11.46
Resident #15 weight loss: 25
Resident #73 weight loss: 15
Resident #15 BIMS score: 5
Resident #69 BIMS score: 5
Latuda dose: 40
Risperdal dose: 0.5
Ativan dose: 0.25
Geodon dose: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff U | Direct Care Staff | Mentioned in hydration deficiency for resident #11. |
| Staff bb | Direct Care Staff | Mentioned in hydration deficiency for resident #11. |
| Staff E | Licensed Nursing Staff | Mentioned in dental and behavior monitoring deficiencies. |
| Staff FF | Social Services Staff | Mentioned in behavior monitoring deficiency. |
| Staff HH | Consulting Pharmacy Staff | Mentioned in psychoactive medication monitoring deficiency. |
| Staff B | Administrative Nursing Staff | Mentioned in hydration and psychoactive medication deficiencies. |
| Staff LL | Licensed Nursing Staff | Mentioned in hydration deficiency. |
Inspection Report
Plan of Correction
Deficiencies: 1
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 (1)
Failure to ensure proper assistance with resident transfers, affecting residents requiring transfer assistance.
Report Facts
Compliance date: Jul 5, 2019
Date resident admitted to hospital: May 4, 2019
Date resident returned to community: May 15, 2019
Number of resident transfers observed weekly: 10
Inspection Report
Plan of Correction
Deficiencies: 6
Date: N008002 POC OZ6S11
Visit Reason
This document is a Plan of Correction submitted by LakePoint Nursing & Rehab Center of El Dorado addressing deficiencies cited during a prior survey.
Findings
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.
Deficiencies (6)
Deficiency related to resident ADL assistance and staff training.
Deficiency related to transfer assistance and safe transfer techniques.
Deficiency related to safe and sanitary dishwashing techniques and dietary staff training.
Deficiency related to proper dating of multi-use pharmacy vials and medication destruction policies.
Deficiency related to infection control practices and environmental staff training.
Deficiency related to dishwashing procedures and dietary management oversight.
Report Facts
Complete Date: Feb 12, 2015
In-service training date: Jan 22, 2015
QA committee review date: Jan 27, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for implementation and ongoing compliance of corrective measures related to resident care, transfer assistance, and medication management. | |
| Dietary Manager | Responsible for dietary staff training, observation, and ensuring safe dishwashing and food handling practices. | |
| Environmental Manager | Responsible for infection control training and oversight of environmental staff. | |
| Administrator | Responsible for implementation and oversight of corrective actions. | |
| Consultant Pharmacist | Reviews medication management system and ongoing compliance. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N008002 POC R08L11
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 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.
Deficiencies (4)
Failure to provide written notice to residents and families upon admission and periodically throughout their stay.
Failure to ensure meals are served at proper temperatures and dietary staff properly operate steam tables.
Multiple kitchen sanitation issues including unlabeled open dates, improper refrigerator temperature, unclean equipment, and unsanitary utensils.
Failure to maintain a consistent infection control program with proper surveillance and tracking.
Report Facts
Complete Date: Oct 16, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vanessa Underwood | Administrator | Submitted the Plan of Correction and responsible for monitoring compliance |
| Irina Strakhova | Added and modified the Plan of Correction |
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