Inspection Reports for Lakepoint Wichita, LLC

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-02-06.

All deficiencies have been corrected as of the compliance date of 2025-02-17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was a Re-Licensure Survey combined with complaint investigations for the Assisted Living Facility conducted on 02/05/25 and 02/06/25.

The facility was found deficient in multiple areas including failure to revise negotiated service agreements after significant changes in resident service needs, failure to safeguard resident records from theft or unauthorized use, incomplete documentation of incidents and follow-up in resident records, lack of quarterly reviews of the emergency management plan with staff and residents, and failure to comply with tuberculosis screening guidelines for new residents.

The visit included complaint investigations numbered 183375, 188093, 188529, 190272, 190241, 190753, and 192504.

The visit was conducted as a Re-Licensure Survey with complaint investigations for the Assisted Living Facility on 02/05/25 and 02/06/25.

The report represents findings from a Re-Licensure Survey combined with multiple complaint investigations for the facility.

Complaint investigations 183375, 188093, 188529, 190272, 190241, 190753, and 192504 were included in the survey.

An offsite revisit survey was conducted on 01/21/25 for all previous deficiencies cited on 12/04/24.

All deficiencies have been corrected as of the compliance date of 01/03/25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was a health resurvey and complaint investigation involving multiple complaint investigations and routine oversight of resident rights, Medicaid/Medicare coverage, notice requirements before transfer/discharge, accident hazards, bowel/bladder incontinence, trauma-informed care, drug regimen review, labeling and storage of drugs, hospice services, payroll based journal submission, and infection prevention and control.

The facility was found deficient in multiple areas including failure to promote resident dignity, failure to provide required Medicaid/Medicare notices, failure to notify the Long Term Care Ombudsman of a resident's discharge, failure to ensure adequate supervision and accident hazard prevention, failure to provide appropriate catheter care and infection control precautions, failure to complete trauma-informed care assessments, failure to ensure proper drug regimen review and documentation, failure to label and store medications properly, failure to coordinate hospice care, failure to submit accurate staffing data, and failure to maintain an effective infection prevention and control program.

This document is a Plan of Correction submitted by Lakepoint Wichita RS following deficiencies identified in the inspection conducted on 12/04/2024.

The Plan of Correction addresses multiple deficiencies including resident rights, Medicaid/Medicare notices, discharge notices, accident hazards, catheter care, trauma informed care, drug regimen reviews, psychotropic medication use, medication labeling and storage, hospice services coordination, payroll based journal compliance, and infection prevention and control.

An offsite revisit survey was conducted on 09/19/24 to verify correction of all previous deficiencies cited on 07/30/24.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/30/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was conducted as a complaint investigation related to allegations identified by complaint investigations KS00189461 and KS00189424.

The facility failed to provide a safe environment for a cognitively impaired resident with a history of multiple falls, resulting in repeated falls including one that caused a fractured wrist. The facility lacked adequate interventions, toileting plans, and root cause analyses to prevent further falls.

The visit was triggered by complaint investigations KS00189461 and KS00189424. The facility was found non-compliant in preventing falls and ensuring resident safety.

This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection at Lakepoint Wichita facility.

The plan addresses corrective actions for residents requiring 1-hour assistance while awake and bowel and bladder care programs following a fall with fracture. The facility outlines measures to identify other residents at risk and monitor compliance through care plan reviews and root cause analysis.

An offsite revisit survey was conducted on 11/14/2023 for all previous deficiencies cited on 09/27/2023.

All deficiencies have been corrected as of the compliance date of 10/17/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was conducted as a result of investigations of multiple complaints (#182988, 181851, 181971, 182563, and 182648) concerning care and medication administration at the facility.

The facility failed to provide bathing opportunities as per resident preferences for three residents and failed to administer medications as ordered for one resident, including narcotic pain medication and antibiotics. Documentation of bathing and medication administration was inconsistent and did not always reflect actual care provided.

The inspection findings represent the results of investigations of complaints #182988, 181851, 181971, 182563, and 182648.

This document is a Plan of Correction submitted in response to deficiencies cited during the inspection of Lakepoint Wichita on 09/27/2023.

The facility was cited for deficiencies related to ADL care for dependent residents and pharmacy services/procedures, specifically regarding documentation of showers and medication administration. The Plan of Correction outlines training and auditing measures to address these deficiencies.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-08-23.

All deficiencies have been corrected as of the compliance date of 2023-09-01, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

Re-Licensure Survey with complaint investigations conducted on 08/21/23, 08/22/23, and 08/23/23 at an Assisted Living facility.

The facility was found deficient in multiple areas including inaccurate functional capacity screening, incomplete negotiated service agreements, inadequate health care services coordination, lack of proper medication self-administration assessments, improper medication storage, incomplete resident incident documentation, failure to conduct quarterly emergency management plan reviews with residents, and non-compliance with tuberculosis screening requirements for new employees.

The inspection included complaint investigations numbered 163931, 166640, 167862, 170490, 171473, 171521, 172312, 174433, 175944, 177122, 179975, 180047, 180574, 181776.

The document is a Plan of Correction related to a Re-Licensure Survey with complaint investigations conducted at an Assisted Living facility on 08/21/23, 08/22/23, and 08/23/23.

The Plan of Correction addresses findings from the Re-Licensure Survey and multiple complaint investigations at the facility during the specified dates.

The visit included complaint investigations with multiple complaint IDs referenced: 163931, 166640, 167862, 170490, 171473, 171521, 172312, 174433, 175944, 177122, 179975, 180047, 180574, 181776.

A revisit survey was conducted on 06/12/23 and 06/13/23 for all previous deficiencies cited on 03/09/23 to verify correction of prior deficiencies.

All previously cited deficiencies have been corrected as of the compliance date 04/21/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was a Health Resurvey and Complaint Investigation triggered by multiple complaint investigations and health resurvey.

The facility was found deficient in multiple areas including failure to provide dignified care during meals and basic cares, failure to issue timely Medicaid notifications, failure to maintain a homelike environment, failure to provide timely transfer/discharge notices, failure to transmit discharge MDS, failure to revise care plans for falls and dementia, failure to assist with hearing aids, failure to provide bathing for dependent residents, inconsistent weekend activities and lack of certified activity professional, failure to maintain range of motion and proper positioning, failure to prevent accidents including improper gait belt use resulting in a fall with fracture, failure to monitor and respond to weight loss, failure to provide consistent dementia care, failure to identify and report medication irregularities, failure to properly store and label medications, failure to maintain food safety and hand hygiene, failure to maintain infection control practices, failure to have a certified infection preventionist, and failure to obtain and document influenza and pneumococcal vaccinations.

The inspection was triggered by multiple complaint investigations KS00178024, KS00177983, KS00175604, KS00175094, and KS00174283.

This document is a Plan of Correction submitted by Lakepoint Wichita in response to deficiencies cited during a regulatory inspection conducted on 03/09/2023.

The facility identified multiple deficiencies related to resident rights, Medicaid/Medicare notices, environment, care planning, activities, infection control, medication management, and dementia care. The plan outlines corrective actions including staff education, audits, care plan revisions, and monitoring through QAPI to achieve substantial compliance by 04/21/2023.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-07-25.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 2022-08-10, and no new non-compliance was found. The facility is in compliance with all regulations surveyed.

The visit was a resurvey of the assisted living facility conducted on 07/21/22 and 07/25/22 to assess compliance with disaster and emergency preparedness requirements.

The administrator failed to ensure disaster and emergency preparedness by not performing quarterly reviews of the emergency management plan with employees, specifically failing to review all required topics such as information about explosions.

This document represents the findings of a resurvey conducted for the Assisted Living facility on 07/21/22 and 07/25/22.

The document provides the provider's plan of correction in response to the findings from the resurvey conducted on the specified dates.

A revisit survey was conducted on 06/08/22 to verify correction of all previous deficiencies cited on 04/20/22.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 05/13/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

A partial extended complaint investigation was conducted based on multiple complaints regarding the facility's compliance with care standards and resident safety.

The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide adequate bathing and personal hygiene for dependent residents, failure to properly identify and confirm a resident's code status during an emergency leading to immediate jeopardy, and failure to safely position a resident in a sling during mechanical lift transfers.

The investigation was triggered by multiple complaints (KS00170998, KS00170924, KS00170746, KS00170748, KS00170751, KS00170752, KS00170754, KS00170755, KS00170758, and KS00170618). The immediate jeopardy was related to failure to identify Resident 6's code status during an emergency, which was removed after the facility implemented corrective actions.

This document is a Plan of Correction submitted by the facility to address deficiencies cited in the related Deficiency Report (2567) dated 04-20-2022.

The facility outlines corrective actions to achieve significant compliance with deficiencies related to resident bathing preferences, CPR policies and procedures, advanced directives, hospital transfer packets, and safe resident transfers including lift training following a fall incident.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 07/22/21.

All deficiencies have been corrected as of the compliance date of 08/18/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was conducted as a Health Resurvey and Complaint investigations related to resident rights, advance directives, transfer and discharge requirements, drug regimen, dialysis care, and other compliance areas.

The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to document advance directives and code status, failure to document required discharge information and provide discharge summaries, failure to notify residents and representatives of hospitalizations and bed-hold policies, failure to complete timely Minimum Data Set (MDS) assessments, failure to document dialysis fistula assessments, and failure to follow physician orders for medication administration and monitoring.

The visit included complaint investigations KS00146876, KS00162057, KS00163490 related to resident rights, advance directives, transfer and discharge, medication management, and dialysis care.

An offsite revisit survey was conducted on 12/22/20 to verify correction of all previous deficiencies cited on 10/28/20.

All deficiencies cited in the previous inspection have been corrected as of 12/11/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by LakePoint Wichita to address deficiencies cited during a prior survey.

The facility developed and implemented a system to assure correction and continued compliance, including staff education on nail care and weekly monitoring of nail care on residents.

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

All previously cited deficiencies were corrected as of the revisit date, with each deficiency fully identified by regulation number and marked as completed.

A complaint survey was conducted on 11/02/20 - 11/03/20 for complaint #KS00157320.

The allegations made in the complaint were not substantiated. No noncompliance was found. The facility was in compliance with all regulations surveyed. A Focused Infection Control Survey 2 (FICS2) was completed and the facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

Complaint #KS00157320 was investigated and found to be unsubstantiated with no noncompliance identified.

The inspection was conducted as a complaint investigation (#KS00157160) regarding the facility's failure to provide adequate nail care for dependent residents.

The facility failed to provide necessary nail care for two residents (R1 and R4), resulting in poor grooming and hygiene. Observations and interviews confirmed that nail care was not performed as expected despite documented care plans and staff responsibilities.

The visit was triggered by complaint investigation #KS00157160. The complaint was substantiated as the facility failed to provide nail care to two residents as required.

Resurvey with complaint investigations conducted on multiple dates in October 2020 to verify correction of previous deficiencies at an assisted living facility.

The facility was found deficient in multiple areas including failure to complete functional capacity screening and negotiated service agreements on admission, inadequate provision of health care services including weight monitoring, medication administration errors, failure to notify medical providers of medication regimen variances, incomplete employee records, inadequate documentation of incidents, failure to conduct quarterly emergency preparedness reviews with residents, and ongoing bed bug infestation with insufficient treatment documentation and control measures.

The inspection was a resurvey with complaint investigations #137211, #141657, #142649, #144747, #144908, #147573, #150095, #150263, #150567, #150621, #150914, #150905, #153176, #153734, #153754, #154836, #155786, #156279, #156395, #156533.

The special infection control survey for COVID-19 was conducted for the facility on 07/08/2020.

The survey resulted in findings of no deficiency citations.

A complaint survey was conducted for complaint #KS00153872.

The allegations made in the complaints were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.

Complaint #KS00153872 was investigated and found to be unsubstantiated.

A COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of the Kansas Department for Aging and Disability Services (KDADS).

The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the COVID-19 focused infection control survey.

The inspection was conducted to evaluate the nursing facility's wireless call light system functionality and compliance with regulatory requirements.

The facility failed to ensure full functionality of the wireless call light system because staff on the 900 hallway did not consistently carry pagers to receive resident call light notifications or escalation notices, resulting in inadequate response to call lights. The facility also lacked a policy on call light response times and pager use.

This document is a Plan of Correction submitted by LakePoint Wichita in response to deficiencies cited during a survey conducted on December 13, 2019.

The Plan of Correction outlines corrective actions to address staffing policies, procedures, and practices, including education of the Administrator and Director of Nursing, implementation of pager procedures, weekly staffing stabilization meetings, installation of call light monitors, and auditing of call light reports to ensure timely response and compliance with state staffing requirements.

An offsite revisit survey was conducted on 12/10/19 for all previous deficiencies cited on 09/25/19 to verify correction of cited deficiencies.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 10/25/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was conducted to evaluate the nursing facility's compliance with nursing facility support systems requirements, specifically focusing on the wireless call light system and its functionality.

The facility failed to ensure nursing staff carried the appropriate pagers to respond adequately to the escalating call light system. Additionally, the facility did not have a functional call light system with visual signals on the 900 and 200 hallways, as wall monitors were nonfunctional and the temporary laptop monitor was inaccessible due to unknown login credentials.

This document is a Plan of Correction submitted by LakePoint Wichita in response to deficiencies cited during a survey conducted on October 23, 2019.

The Plan of Correction outlines corrective actions including staff education on bowel and bladder assessment, comprehensive care plan documentation audits, staffing policy education, installation of call light monitors, and auditing of call light response to ensure compliance with regulations.

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

The Plan of Correction outlines multiple corrective actions including staff education on resident rights, care plan revision, restorative services, infection control, and blood sugar monitoring policies, with audits scheduled to ensure compliance.

The inspection was conducted as a Health Resurvey and Complaint Investigations #139275 and #141772.

The facility was found deficient in multiple areas including resident rights and dignity, care plan timing and revision, activities of daily living, ADL care for dependent residents, nutrition and hydration status maintenance, drug regimen review and monitoring, frequency of meals/snacks at bedtime, and infection prevention and control.

The visit was triggered by complaint investigations #139275 and #141772.

An offsite revisit survey was conducted on 09/17/19 for all previous deficiencies cited on 08/01/19 to verify correction of cited deficiencies.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/30/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

An offsite revisit survey was conducted on 08/26/19 to verify correction of all previous deficiencies cited on 07/11/19.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/19/19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was conducted as a complaint investigation identified by KS00143922 regarding the facility's resident call light system.

The facility failed to have a resident call light system that escalated periodically when staff did not respond within a designated time frame. Observations and interviews confirmed that not all nursing staff carried pagers and the facility lacked an escalating call light system as required.

The citation represents findings from complaint investigation KS00143922. The facility lacked an escalating call light system and did not have enough pagers for all nursing staff, including charge nurses.

This document is a Plan of Correction submitted in response to deficiencies cited during a survey of LakePoint Wichita.

Deficiencies included lack of guidance for an escalating call light system and inadequate wound care protocols. The facility developed and implemented corrective actions including re-education of licensed nurses and establishment of new policies to ensure compliance.

The inspection was conducted as a result of complaint investigations KS00143168 and KS00142860.

The facility failed to review and revise care plans after resident falls to include appropriate fall prevention strategies based on root cause analysis, failed to provide necessary bathing services to maintain grooming and hygiene for some residents, failed to ensure adequate supervision to prevent falls, failed to check feeding tube placement prior to administering fluids and medications, and failed to develop collaborative hospice care plans including both hospice and facility services.

The inspection was triggered by complaint investigations KS00143168 and KS00142860.

This document is a Plan of Correction submitted by LakePoint Wichita in response to deficiencies cited during the inspection survey conducted on 7/11/2019.

The plan outlines corrective actions including education for licensed nurses on root cause analysis and fall prevention, updating resident bathing preferences, re-education on PEG tube policies, and improving hospice care plan documentation to ensure compliance with regulations.

The health survey and complaint investigations #KS00127938, KS00124143, KS00122469, KS00122153, and KS00118023 were conducted to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B, for long term care facilities.

The survey and complaint investigations resulted in a finding of no deficiency citations with respect to the applicable regulations.

Complaint investigations #KS00127938, KS00124143, KS00122469, KS00122153, and KS00118023 were conducted and found no deficiencies.

The document is a Plan of Correction related to a Health Survey and multiple complaint investigations at the facility.

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

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

All previously cited deficiencies listed by regulation numbers were corrected as of the revisit date, with completion dates documented for each.

The inspection was a resurvey with complaint investigations (#106281, #1227678, #126527, and #128060) conducted on 7/3, 7/5, and 7/9/2018 at an assisted living facility.

The inspection found multiple deficiencies including failure to develop complete negotiated service agreements for residents, lack of nurse identification responsible for health service plans, incomplete self-administration medication assessments, improper labeling of over-the-counter medications, failure to conduct quarterly emergency management plan reviews with staff and residents, and non-compliance with tuberculosis screening guidelines.

The visit was a resurvey with complaint investigations identified by complaint numbers #106281, #1227678, #126527, and #128060.

An off-site survey was conducted to review deficiencies cited on December 15, 2017.

The deficiencies cited on December 15, 2017, were corrected as of the compliance date of January 14, 2018.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be a 'D' level deficiency 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 effective January 14, 2018.

The inspection was conducted as a complaint investigation (#124122) regarding allegations of abuse, neglect, and exploitation at the facility.

The facility failed to report 2 of 3 allegations of potential abuse, neglect, and/or exploitation to the state agency and failed to conduct thorough investigations for these allegations. Specifically, the facility did not report an allegation of potential abuse involving Resident #1 and an allegation of potential misappropriation of money involving Resident #2. Investigations were incomplete and did not include interviews with all relevant parties.

The complaint investigation #124122 involved allegations that the facility failed to report and properly investigate potential abuse and misappropriation of resident property. Resident #1 reported inappropriate touching which was not reported to the state agency. Resident #2 reported a missing check which was not reported to the state agency. Both allegations were not thoroughly investigated as required.

The document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation survey at LakePoint Wichita.

The complaint investigation found the complaint against Resident #1 to be unfounded due to a medical condition that has since been resolved. Issues included a misplaced check for Resident #2 that was not cashed, which was subsequently reissued. The facility implemented corrective actions including staff education on abuse/neglect policies and ongoing resident interviews to monitor compliance.

Complaint was investigated immediately on 2017-11-27 and found to be unfounded due to a medical condition. Resident #1 was interviewed again on 2017-12-12 with no complaints. Resident #2 was discharged on 2017-12-14; a misplaced check was reissued on 2017-12-05.

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

The report confirms that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(d)(1)(2)(n)(1)-(3) was corrected as of 05/12/2017. No other deficiencies or uncorrected issues are noted.

An abbreviated survey was conducted on May 3, 2017, by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety. Deficiencies were cited at a level of actual harm or above, leading to enforcement remedies including denial of payment for new admissions.

Complaint investigation #114609 and a partially extended survey were conducted to assess the facility's compliance with regulations related to accident hazards, supervision, and use of devices to prevent accidents, specifically focusing on elopement risks.

The facility failed to accurately assess residents' risk for elopement and to develop individualized interventions to prevent elopement for three residents. Resident #1 exited the building without staff knowledge, resulting in a fall outside the facility. The facility also failed to properly complete wander guard assessments and implement appropriate interventions for residents #2 and #3, placing them at risk for elopement.

Complaint investigation #114609 focused on accident hazards related to risk of elopement for three residents. The investigation found failures in assessment and intervention implementation that placed residents at risk, including an immediate jeopardy event involving resident #1 exiting the facility unnoticed and falling.

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

The revisit confirmed that the previously cited deficiencies, specifically those under regulation 483.10(c)(6)(8)(g)(12) and 483.24(a)(3), were corrected as of 04/14/2017.

An abbreviated survey was conducted on April 5, 2017, by the Kansas Department for Aging & Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted immediate jeopardy to resident health or safety. Deficiencies were cited that constituted a level of actual harm or above, leading to enforcement remedies including denial of payment for new admissions.

The inspection was conducted as a complaint investigation (#113849) regarding the facility's failure to follow a resident's advance directives related to cardiopulmonary resuscitation (CPR).

The facility failed to initiate CPR for Resident #1 who was a full code and expressed a desire for CPR, resulting in the resident's death. Staff did not follow the resident's advance directives, placing the resident in immediate jeopardy. The facility implemented corrective actions to address the failure.

The complaint investigation #113849 found that staff failed to initiate CPR for Resident #1 who was a full code and unresponsive, resulting in the resident's death. The facility's failure to honor the resident's advance directives placed the resident in immediate jeopardy.

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

All previously cited deficiencies were corrected as of the revisit date, with completion dates documented for each deficiency.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

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, and the facility was found to be in substantial compliance effective January 6, 2017.

Annual health resurvey of Lakepoint Retirement & Rehab Center of Wichita to assess compliance with federal regulations related to resident care, safety, and facility operations.

The facility was found deficient in multiple areas including failure to timely convey resident funds upon death, failure to honor resident preferences for wake time and bathing, inadequate individualized activity programs, incomplete comprehensive care plans, failure to revise care plans for pressure ulcers, inadequate oral care, inconsistent pressure ulcer monitoring and treatment, unsafe bed rail positioning, insufficient hydration practices, and failure to monitor and report blood sugar irregularities and medication effects.

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

The Plan of Correction addresses multiple deficiencies related to resident funds management, honoring resident preferences for care and activities, wound care, oral care, bed safety, hydration, medication management, and behavior management. The facility outlines corrective actions including staff education, care plan updates, audits, and ongoing monitoring to ensure compliance.

This revisit report documents the correction of deficiencies previously cited during an earlier survey of the facility.

The report confirms that all previously identified deficiencies have been corrected as of the revisit date.

The inspection was conducted as an Assisted Living/Residential Healthcare Licensure resurvey combined with complaint investigations #89409 and #100251.

The facility failed to make the most recent survey report available to residents, staff, and visitors; failed to make the emergency management plan available; and failed to maintain a safe environment related to unlocked chemicals, posing potential risks to residents.

The visit included complaint investigations #89409 and #100251 as stated in the initial comments.

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

The revisit report indicates that the deficiencies previously cited under regulation numbers 483.10(b)(11) and 483.25 were corrected as of 06/30/2016.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

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

The inspection was conducted as a complaint investigation (#KS00100681) regarding the facility's failure to notify the physician and legal representative of a significant change in a resident's medical condition.

The facility failed to immediately inform the physician and legal guardian/representative of a significant change in medical condition (decreased level of consciousness) for one resident. Additionally, the facility failed to provide timely and thorough nursing assessments, including vital signs monitoring, during the resident's decline, resulting in inadequate care to maintain the resident's highest practicable physical well-being.

The complaint investigation (#KS00100681) focused on the facility's failure to notify the physician and legal representative of Resident #1's significant change in condition and failure to provide adequate nursing assessments during the resident's decline.

This document is a Plan of Correction submitted by LakePoint Wichita in response to deficiencies cited during a complaint survey conducted on 06/02/2016.

The facility developed and implemented a system to assure correction and continued compliance with regulations, including educating licensed nursing staff on physician notification and nursing assessments related to changes in resident conditions, and performing ongoing audits reviewed by the QA committee.

This Plan of Correction addresses deficiencies cited during a complaint investigation at LakePoint Retirement on 06/02/2016.

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

The survey found the most serious deficiencies to be at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.

This post-certification revisit was conducted to verify that previously identified deficiencies at Lakepoint Retirement & Rehab Center of Wichita were corrected.

The report confirms that all previously cited deficiencies identified by regulation numbers 483.15(e)(1), 483.25(c), 483.25(l), 483.35(i), and 483.60(c) were corrected as of the revisit date.

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

The revisit confirmed that the deficiencies identified under regulations 483.10(b)(11) and 483.25 were corrected as of 06/14/2015.

The inspection was conducted as a health resurvey and complaint investigations related to multiple complaint numbers.

The facility was found deficient in multiple areas including failure to ensure residents had accessible call lights, inadequate pressure ulcer prevention and treatment, failure to prevent unnecessary drug use and inadequate monitoring of psychotropic medications, unsanitary food handling practices, and failure of the pharmacist to report medication regimen irregularities.

The inspection included complaint investigations #86839, #81765, #85512, #83803, #83737, #82387, and #81723.

This document is a Plan of Correction submitted by LakePoint Wichita to address deficiencies cited during a prior survey.

The plan outlines corrective actions for multiple deficiencies including call light placement, pressure ulcer management, psychotropic medication behavior monitoring, and food safety practices. The facility has implemented audits, staff education, and ongoing monitoring to ensure compliance.

An Abbreviated survey on May 15, 2015 and a Health survey on May 28, 2015 were conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The surveys found the most serious deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted plans of correction and was found to be in substantial compliance based on credible allegation of compliance and the plans of correction.

The visit 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, through an Abbreviated survey on May 15, 2015 and a Health survey on May 28, 2015.

The surveys found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted plans of correction which were accepted, resulting in a finding of substantial compliance effective June 26, 2015.

The inspection was an abbreviated survey conducted for investigation of complaint #KS00084354 regarding the facility's failure to notify the physician of significant changes in a resident's medical condition.

The facility failed to immediately notify the physician when Resident #2 experienced significant changes in medical condition, including low blood pressure readings and brief deterioration in level of consciousness. Additionally, the facility failed to provide timely and thorough nursing assessments and reassessments to maintain the resident's highest practicable physical well-being.

Investigation of complaint #KS00084354 found substantiated failures related to physician notification and resident care for Resident #2.

This document is a Plan of Correction submitted by Lakepoint Retirement in response to deficiencies cited during a complaint investigation survey conducted on 2015-05-15.

The facility was cited for deficiencies including failure to follow standing orders regarding blood pressure and failure of licensed nurses to follow up and reassess residents in a timely manner. The plan outlines corrective actions including staff education and ongoing nursing documentation review.

This Plan of Correction is related to a complaint investigation survey conducted on 2015-05-15.

This revisit report documents the correction of deficiencies previously reported during a prior survey, verifying that corrective actions were accomplished.

The report confirms that the previously cited deficiencies identified by regulation numbers 26-41-201(c), 26-41-202(d), and 26-41-204(d) were corrected as of 10/15/2014.

This document is a Plan of Correction submitted by Lake Point Wichita Assisted Living in response to deficiencies cited during a complaint-related survey.

The facility had deficiencies related to incomplete or untimely Functional Capacity Screens, Negotiated Service Agreements, and Health Service Plans, particularly concerning residents with significant changes in condition such as wounds or ulcers.

This Plan of Correction addresses deficiencies cited during a complaint investigation survey at Lake Point Wichita Assisted Living.

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

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but 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.

Investigation of complaint #78547 regarding failure to complete required functional capacity screens and negotiated service agreements following significant changes in resident condition.

The facility failed to complete functional capacity screens and negotiated service agreements within required timeframes for residents with significant changes in condition, specifically related to wound care. The facility also failed to complete a health care service plan including the description of health care services and the responsible licensed nurse for one resident with a wound.

Investigation of complaint #78547 regarding failure to complete required functional capacity screens and negotiated service agreements following significant changes in resident condition.

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

The report confirms that deficiencies identified in prior inspections, specifically those referenced by regulation numbers 28-39-158(c) and 28-39-158, were corrected as of 08/20/2014.

The inspection was conducted as a result of complaint investigations #77231, 77166, and 75440 regarding food service and sanitation issues at the facility.

The facility failed to serve food at proper temperatures, with hot foods below required temperatures and no monitoring of cold food temperatures. Additionally, the facility failed to maintain sanitary conditions in the kitchen, including inadequate cleaning of equipment, surfaces, and improper sanitization procedures.

The inspection findings are based on complaint investigations #77231, 77166, and 75440. The complaints were substantiated as evidenced by the cited deficiencies.

This document is a Plan of Correction submitted in response to deficiencies cited during a complaint survey at LakePoint Wichita Assisted Living.

Deficiencies involved food temperature control, sanitation and cleaning of kitchen equipment, and proper documentation and training related to these areas. Corrective actions include staff education, calibration of thermometers, removal of salad bar, replacement of oven, and implementation of cleaning and audit schedules.

This Plan of Correction is related to a complaint survey as indicated by the reference to 'Complaint' in the deficiency report link and the nature of the deficiencies addressed.

This report documents a revisit conducted to verify correction of previously cited deficiencies at the facility.

The revisit confirmed that the previously reported deficiency identified by regulation 28-39-156(f) was corrected as of 03/07/2014.

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

The report shows that deficiencies identified under regulations 483.25 and 483.60(a),(b) were corrected as of 03/07/2014, indicating compliance with the required corrective actions.

This revisit report documents the correction of deficiencies previously reported during an earlier survey, verifying that corrective actions were accomplished.

The report confirms that previously identified deficiencies with ID prefixes S1166 and S1172 were corrected as of 03/07/2014.

This report documents a post-certification revisit to verify correction of previously cited deficiencies at Lakepoint Retirement & Rehab Center of Wichita.

All previously reported deficiencies identified on the CMS-2567 were corrected as of 03/07/2014, with corrective actions completed for each cited regulation.

This document is a Plan of Correction submitted by LakePoint Wichita to address deficiencies cited during a prior survey and to outline corrective actions and timelines for compliance.

The Plan of Correction details multiple deficiencies related to resident care, documentation, medication administration, staff education, and facility procedures. The facility outlines specific corrective actions, education plans, audits, and monitoring to achieve substantial compliance by March 7, 2014.

The visit was a licensure resurvey of the facility to assess compliance with regulatory requirements.

The licensure resurvey resulted in a finding of no deficiency citations.

Annual health resurvey of Lakepoint Retirement & Rehab Center of Wichita to assess compliance with federal nursing home regulations.

The facility had multiple deficiencies including failure to provide required liability notices, failure to ensure residents' rights to make choices, failure to maintain sanitary environment, incomplete comprehensive assessments, failure to update care plans, inadequate monitoring of fluid restrictions and dialysis care, insufficient staffing, failure to follow up on PRN medications, and failure to secure medications properly.

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

The Plan of Correction outlines corrective actions taken to address deficiencies related to bowel movement monitoring, medication documentation, and medication destruction procedures to ensure compliance with regulations.

The inspection was conducted as a complaint investigation based on complaints #71262 and #71909 regarding medication destruction practices at the facility.

The facility failed to ensure that discontinued, outdated, and unused medications were destroyed by a pharmacist and a licensed nurse as required by state regulations. Instead, certified medication aides destroyed medications without proper oversight or documentation, posing potential risk to all residents.

The investigation was triggered by complaints #71262 and #71909. The facility did not follow proper medication destruction procedures, allowing CMAs to destroy medications alone or with another person, without pharmacist involvement or proper documentation.

This report documents a revisit inspection to verify correction of previously cited deficiencies at Lakepoint Retirement & Rehab Center of Wichita.

The revisit inspection confirmed that previously reported deficiencies identified by regulation numbers 26-39-103 (b), 26-41-204 (i), and 26-41-205 (l)(1) were corrected as of 11/22/2013.

The inspection was conducted as a complaint investigation based on complaint numbers #69545 and #69559.

The facility failed to ensure one resident was free from interference and coercion regarding attending activities, failed to provide bathing as frequently as directed in health service plans for two residents, and failed to adequately monitor and document the administration and effectiveness of PRN and psychotropic medications for two residents.

The complaint investigation involved allegations related to resident rights violations, bathing assistance, and medication regimen monitoring for specific residents.

This document is a Plan of Correction submitted by LakePoint Wichita Assisted Living in response to deficiencies cited during a prior survey.

The plan addresses multiple deficiencies including allowing residents to attend activities despite inappropriate behaviors, bathing assistance and documentation issues, and medication review and management particularly related to PRN and psychotropic medications.

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

The report confirms that the deficiency identified under regulation 26-40-303 was corrected as of the revisit date, November 14, 2012.

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

The revisit confirmed that all previously cited deficiencies related to regulations 483.20(b)(2)(ii), 483.20(d), 483.20(k)(1), 483.20(d)(3), 483.10(k)(2), and 483.25(d) were corrected as of 11/14/2012.

The inspection was conducted as a health resurvey and investigation into complaints #58992 and #59731 regarding the facility's nursing call system.

The facility failed to have a wireless call system that repeated unanswered signals every three minutes and did not ensure that all staff carried pagers as required. Multiple residents reported delays in staff responding to call lights, and staff interviews confirmed inconsistent pager use and lack of guidance on locating residents.

The visit was triggered by complaints #58992 and #59731. The findings substantiated issues with the nursing call system and staff response times.

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

The report shows that all previously cited deficiencies were corrected as of 08/11/2011, with no uncorrected deficiencies noted at the time of this revisit.

The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements and investigate specific complaints.

The facility was found deficient in multiple areas including failure to properly assess and provide appropriate bedrails, failure to follow resident choices regarding wake times, inadequate discharge planning, incomplete comprehensive assessments, inaccurate assessments, failure to develop and revise comprehensive care plans, inadequate personal hygiene care, unsafe environment hazards, failure to monitor medication effectiveness, failure to maintain sanitary food service conditions, and failure to implement effective infection control practices.

The visit included a complaint investigation (#48608) related to multiple issues including restraint use, resident rights, discharge planning, assessment accuracy, care planning, personal hygiene, environmental safety, medication monitoring, food sanitation, and infection control.

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

The plan outlines corrective actions addressing deficiencies related to hospice care assessments, catheter care, care plan updates, call system alerts, and related staff education and audits to ensure compliance.

This document is a Plan of Correction submitted by LakePoint Wichita in response to deficiencies cited during a complaint investigation survey.

The facility developed and implemented a system to assure correction and continued compliance, including updated wander assessment tools, staff education, policy revisions, and ongoing audits to prevent elopement incidents.

This Plan of Correction is related to a complaint investigation identified as Lakepoint Wichita complaint 05032017.

This document is a Plan of Correction submitted by LakePoint Wichita Assisted Living in response to deficiencies cited during a prior survey.

The facility developed and implemented corrective actions to address deficiencies including posting the survey report, posting the Emergency Management Plan, and ensuring chemicals are stored in a locked environment.

This document is a Plan of Correction submitted by LakePoint Wichita in response to deficiencies cited during a complaint investigation survey.

The facility developed and implemented a system to assure correction and continued compliance with regulations, specifically addressing issues related to code status and advance directives following the death of a resident.

The visit was complaint-related, addressing concerns about honoring advance directives and code status for residents who are full code.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.

The Plan of Correction outlines corrective actions for multiple deficiencies including staff phone use during resident care, code status documentation, discharge documentation, hospitalization notifications, bed hold policy, timely completion of discharge/death MDS, discharge summaries, post-dialysis assessments, and medication oversight.