Inspection Reports for
Lakepoint Wichita, LLC

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

The facility was found deficient in multiple areas including failure to revise negotiated service agreements after significant changes in resident service needs, inadequate safeguarding of resident records, incomplete documentation of incidents in resident records, failure to conduct required quarterly emergency management plan reviews, and noncompliance with tuberculosis screening guidelines.

The inspection was conducted as a complaint investigation for multiple complaint numbers KS00191939, KS00190832, and KS00190273.

The facility was found deficient in multiple areas including resident dignity, Medicaid/Medicare coverage notices, transfer/discharge notices, accident hazards, catheter care, trauma-informed care, drug regimen review, psychotropic medication use, medication labeling and storage, hospice services coordination, payroll-based journal staffing data submission, and infection prevention and control.

The facility had multiple deficiencies including failure to promote resident dignity, incomplete medication management (missing stop dates and physician rationales), inadequate infection control practices, failure to coordinate hospice care plans, inaccurate staffing data submission, and unsafe storage of medications and chemicals.

The facility had multiple deficiencies including failure to promote resident dignity, incomplete medication management and documentation, inadequate infection control practices, failure to coordinate hospice care, inaccurate staffing data submission, and failure to maintain waterborne pathogen prevention.

The facility identified multiple deficiencies related to resident rights, Medicaid/Medicare notices, discharge procedures, accident hazards, catheter care, trauma-informed care, medication management, hospice services, payroll-based journal compliance, and infection prevention and control. Corrective actions and staff education plans are outlined for each deficiency.

The Plan of Correction addresses deficiencies related to resident care, specifically involving a resident requiring 1-hour assistance while awake and a bowel and bladder 72-hour program following a fall with fracture. The facility implemented corrective actions including updating care plans and monitoring compliance.

The investigation was complaint-driven, focusing on the facility's failure to prevent repeated falls for Resident 2. The complaint was substantiated with findings of inadequate fall prevention interventions and lack of a toileting plan.

The facility failed to implement effective interventions to prevent repeated falls for Resident 2, who experienced multiple falls including one resulting in a fractured wrist. The resident was cognitively impaired, had a history of falls, and lacked a toileting plan, contributing to unsafe conditions and repeated accidents.

The findings represent the results of 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 facility failed to provide bathing opportunities as per resident preferences for three residents and failed to administer medications as ordered for one resident, resulting in minimal harm or potential for actual harm to a few residents.

The visit was triggered by investigations of complaints #182988, 181851, 181971, 182563, and 182648.

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 and timely administration issues were noted.

The facility was found deficient in ADL care provided for dependent residents and pharmacy services/procedures related to medication administration and documentation.

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

The survey found multiple deficiencies including inaccurate functional capacity screenings, incomplete negotiated service agreements, inadequate health care service coordination, missing medication self-administration assessments, unsecured medication storage, incomplete resident incident documentation, lack of quarterly emergency management plan reviews with residents, and noncompliance with tuberculosis screening for new employees.

The facility was cited for multiple deficiencies related to resident rights, Medicare/Medicaid notices, care planning, infection control, medication management, dementia care, nutrition, and safety. The Plan of Correction outlines corrective actions including staff education, audits, and monitoring to achieve compliance.

The inspection was complaint-related involving allegations of resident rights violations, medication errors, infection control deficiencies, and inadequate care planning.

The facility was found deficient in multiple areas including resident dignity and care during meals and basic cares, Medicaid/Medicare coverage notifications, safe and homelike environment, transfer and discharge notice requirements, care plan revisions, activities of daily living assistance, activities programming and qualifications, mobility and accident prevention, drug regimen review and unnecessary medication use, medication storage and labeling, food safety and infection control practices, infection preventionist qualifications, and vaccination documentation.

The facility failed to ensure dignified care during meal service, timely notification of Medicare coverage changes, maintenance of a homelike environment, timely transfer notifications, completion and transmission of MDS, individualized care plans, adequate assistance with activities of daily living, fall prevention, nutrition management, dementia care, medication administration within physician parameters, infection control, and vaccination documentation. Several residents were affected by these deficiencies.

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

The investigation was triggered by multiple complaints (KS00170998, KS00170924, KS00170746, KS00170748, KS00170751, KS00170752, KS00170754, KS00170755, KS00170758, and KS00170618). The facility was found not in substantial compliance and immediate jeopardy was identified related to failure to identify code status during an emergency.

The facility was found not in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to provide and document bathing care for dependent residents, failure to appropriately identify and confirm a resident's code status during an emergency resulting in immediate jeopardy, and failure to safely position a resident during mechanical lift transfers.

The facility identified deficiencies related to resident bathing preferences, CPR policies and procedures, proper posting of resident name tags, hospital transfer packets, and safe lift and transfer training. The Plan of Correction outlines staff education, audits, and ongoing monitoring to achieve compliance.

The visit was complaint-related, triggered by allegations of poor resident care including dignity violations, lack of documentation of advanced directives, inadequate discharge and hospitalization procedures, failure to complete required assessments, and medication management issues.

The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to document advanced directives, inadequate discharge documentation and notification, failure to complete timely MDS assessments, failure to assess and document dialysis fistula site, and failure to follow physician orders for medication administration and monitoring.

The inspection included complaint investigations KS00146876, KS00162057, KS00163490.

The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to document and follow advance directives, 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 MDS assessments, failure to provide proper dialysis care documentation, and failure to follow physician orders for medication administration and monitoring.

The facility developed and implemented a system to assure correction and continued compliance with regulations. Specific corrective actions include educating direct care staff on nail care and weekly monitoring of nail care on residents.

The complaint investigation #KS00157160 found substantiated deficiencies related to inadequate nail care for dependent residents.

The facility failed to provide adequate nail care for two residents, R1 and R4, which affected their grooming, hygiene, and comfort. Observations and interviews confirmed that nail care was not performed as expected during showers.

This 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 facility was found deficient in multiple areas including functional capacity screening on admission, admission negotiated service agreements, provision of health care services, medication administration, medication regimen review notifications, staff qualifications, incident documentation, disaster preparedness, infection control, and tuberculosis screening. Additionally, there was an ongoing bed bug infestation with inadequate treatment documentation.

The facility developed and implemented a system to assure correction and continued compliance with regulations, focusing on staffing policies, call light response procedures, and communication with residents.

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. The facility also lacked a policy on call light response times and pager use.

The plan outlines corrective actions including staff education on bowel and bladder assessment, comprehensive care plan documentation, staffing policies, call light response systems, and monitoring procedures to ensure compliance with regulations.

The facility failed to ensure nursing staff carried appropriate pagers for the escalating call light system and lacked functional visual call light monitors on the 900 and 200 hallways. The preventative maintenance program did not ensure weekly testing of the call system, resulting in nonfunctional monitors and inaccessible laptop monitors.

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

The facility was found deficient in multiple areas including failure to treat residents with dignity during feeding, failure to update care plans with physician orders, failure to provide restorative services and scheduled bathing, inadequate monitoring of fluid restrictions and blood sugar levels, failure to offer evening snacks, and infection control lapses including improper glove use and inadequate disinfection of shared equipment.

The citation represents findings of complaint investigation KS00143922. The facility failed to meet requirements for a wireless call light system that escalates unanswered calls to additional staff.

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 facility identified deficiencies related to the call light system and wound care protocols. Corrective actions include re-education of licensed nurses on revised call light policies and new wound care protocols to ensure compliance and promote resident safety.

The plan addresses multiple deficiencies including fall prevention, bathing preferences documentation, PEG tube policy compliance, and hospice care plan collaboration. The facility outlines education, audits, and monitoring processes to ensure compliance and correction of cited deficiencies.

The inspection was triggered by 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. The facility also failed to provide necessary bathing services to maintain good hygiene for some residents, ensure adequate supervision to prevent falls, provide appropriate treatment for feeding tube management, and develop collaborative hospice care plans.

All previously cited deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date.

The inspection was triggered by complaints numbered #106281, #1227678, #126527, and #128060.

The facility was found deficient in multiple areas including failure to develop complete negotiated service agreements, incomplete self-administration medication assessments, improper labeling of over-the-counter medications, lack of quarterly emergency management plan reviews with staff and residents, and failure to comply with tuberculosis screening guidelines.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance as of January 14, 2018.

The complaint investigation #124122 involved allegations of abuse, neglect, and exploitation including a resident reporting inappropriate touching and a missing check. The facility failed to report these allegations to the state agency and did not conduct thorough investigations as required.

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. The investigation lacked interviews with involved staff and other residents, and the facility did not report a potential misappropriation of money.

The complaint investigation was initiated due to a resident complaint. The complaint was investigated immediately on 11/27/2017 and found to be unfounded due to a medical condition that has since been resolved. Resident #1 was interviewed again with no complaints. Resident #2 was discharged and a misplaced check was reissued.

The complaint investigation found the complaint unfounded due to a medical condition that has since been resolved. Issues included a misplaced check that had not been cashed, which was subsequently reissued. The facility developed and implemented a system to assure correction and continued compliance with regulations.

The report confirms that the previously reported deficiencies have been corrected as of the dates indicated, with no uncorrected deficiencies noted at the time of this revisit.

The facility was found not in substantial compliance, with conditions constituting immediate jeopardy to resident health or safety related to F323, "J", CFR 483.25(d)(1)(2)(n)(1)-(3). Enforcement remedies including denial of payment for new admissions were imposed.

This Plan of Correction addresses deficiencies cited during a complaint investigation survey at LakePoint Wichita on 05/03/2017.

The facility developed and implemented a system to assure correction and continued compliance with regulations, including updated wander assessment tools and revised policies to prevent elopement.

Complaint investigation #114609 focused on elopement risk and prevention measures for three residents, triggered by an incident where resident #1 exited the facility unnoticed and fell outside.

The facility failed to accurately assess residents' elopement risk and implement individualized interventions, placing residents at immediate jeopardy. Three residents were reviewed, with findings of incomplete or inaccurate wander risk assessments and failure to use results to prevent elopement incidents.

The complaint investigation #113849 found that staff failed to honor the advance directives of Resident #1 who was a full code and desired CPR. Staff did not initiate CPR when the resident was found unresponsive and without pulse or respirations on 3/26/17, resulting in the resident's death. The facility abated the immediate jeopardy on 3/31/17 by staff education, policy revision, and training.

The facility failed to initiate CPR for a full code resident who was found unresponsive and without respirations, resulting in the resident's death. Staff did not follow the resident's advance directives, placing the resident in immediate jeopardy.

The survey found the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety. Enforcement remedies including denial of payment for new admissions were imposed.

The facility was found deficient in multiple areas including failure to timely convey resident funds after death, failure to honor resident preferences for wake time and bathing, inadequate individualized activity programs, incomplete comprehensive care plans, inadequate pressure ulcer monitoring and treatment, failure to provide oral care, unsafe bed rail gaps, insufficient hydration for a resident requiring thickened fluids, and failure to monitor and report blood sugar and blood pressure irregularities.

The survey found isolated 'D' level deficiencies constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.

The Plan of Correction addresses multiple deficiencies related to resident funds, care plan updates, resident preferences, wound care, oral care, bed rail safety, hydration, medication management, and pharmacy reviews. The facility has implemented corrective actions including staff education, audits, and care plan revisions to ensure compliance.

All previously cited deficiencies identified by regulation or Life Safety Code provisions were corrected as of the revisit date.

The visit included complaint investigations #89409 and #100251.

The facility failed to make the most recent survey report and emergency management plan available to residents, staff, and visitors. Additionally, the facility did not maintain a safe environment related to unlocked chemicals accessible to cognitively impaired and independently mobile residents.

The complaint investigation #KS00100681 was substantiated, finding the facility failed to notify the physician and legal representative promptly and failed to provide adequate nursing assessments for resident #1 during a significant change in 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 change in condition.

The facility developed and implemented a system to assure correction and continued compliance with regulations, including staff education and audits related to physician notification and nursing assessments for changes in resident condition.

The survey found the most serious deficiencies to be 'D' level, indicating no actual harm but 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.

The report confirms that deficiencies previously reported on the CMS-2567 have been corrected as of the revisit date.

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

The facility failed to ensure residents had accessible call lights, failed to provide proper care for pressure ulcers, failed to prevent unnecessary drug use, failed to maintain sanitary food handling practices, and failed to ensure pharmacist review and reporting of medication irregularities.

The facility implemented corrective actions for deficiencies related to call light placement, pressure ulcer management, behavior monitoring for residents on psychotropic medications, and food safety practices. Audits, staff education, and ongoing monitoring were planned to ensure compliance.

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 which were accepted, resulting in a finding of substantial compliance effective June 26, 2015.

The visit was triggered by complaint #KS00084354. The complaint was substantiated as the facility failed to notify the physician and provide adequate care for resident #2's significant medical changes.

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

This plan of correction addresses deficiencies cited during a complaint investigation survey at Lakepoint Retirement.

Deficiencies involved failure to follow physician standing orders regarding blood pressure monitoring and failure of licensed nursing staff to timely reassess residents and notify physicians of decline in condition.

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 and was found to be in substantial compliance based on credible allegation of compliance.

The report confirms that the 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.

Investigation of complaint #78547 regarding failure to complete required functional capacity screens and related care plan updates for residents.

The facility failed to complete functional capacity screens, negotiated service agreements, and health care service plans for residents following significant changes in condition, specifically related to wound care. Documentation and monitoring of wounds were inadequate, and communication with primary care providers was delayed or incomplete.

The survey found the most serious deficiencies to be 'F' level, 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.

The report confirms that deficiencies identified in prior inspections have been corrected as of the revisit date.

The findings represent the results of complaint investigations #77231, 77166, and 75440.

The facility failed to serve food at proper temperatures and maintain sanitary conditions in the kitchen. Observations revealed hot foods served below required temperatures, lack of cold food temperature monitoring, and inadequate cleaning and sanitizing of kitchen equipment and surfaces.

The report confirms that the previously cited deficiency under regulation 28-39-156(f) was corrected as of 03/07/2014. No other deficiencies are listed as outstanding.

The report confirms that the deficiencies previously cited under regulations 483.25 and 483.60(a),(b) were corrected as of 03/07/2014.

The report documents that previously cited deficiencies under regulations 26-40-303 (b)(i)(ii)(iii)(iv)(c) and 26-40-303 (h) were corrected as of 03/07/2014.

The report confirms that all deficiencies previously cited on the CMS-2567 Statement of Deficiencies have been corrected as of March 7, 2014.

The plan details multiple deficiencies related to resident care, documentation, medication administration, staff education, and facility systems such as call light monitoring and treatment cart security. The facility outlines corrective actions including staff education, audits, policy revisions, and quality assurance reviews to achieve substantial compliance by March 7, 2014.

The facility developed and implemented a system to assure correction and continued compliance with regulations related to bowel movement monitoring, medication documentation, and medication destruction procedures.

The facility was found deficient in multiple areas including failure to provide required notices to residents, failure to ensure residents' rights to make choices, failure to maintain sanitary environment, incomplete comprehensive assessments, failure to revise 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.

The findings represent the results of complaint investigations #71262 and #71909. The complaint was substantiated based on interviews and record reviews showing improper medication destruction practices.

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. Certified medication aides destroyed medications alone or with another person without pharmacist involvement, and the facility's medication destruction policy lacked required documentation and procedural details.

The plan outlines corrective actions for deficiencies related to resident activities, bathing assistance, and medication management, including education of staff and ongoing audits to ensure compliance.

The investigation was initiated due to complaints alleging interference with resident rights and inadequate care practices. The complaints were substantiated based on findings related to resident rights violations and care deficiencies.

The facility failed to ensure one resident was free from interference and reprisal regarding activity attendance. The facility also 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 report documents that the previously reported deficiency identified by regulation 26-40-303 was corrected as of the revisit date.

The facility developed and implemented corrective actions to address deficiencies related to hospice care assessments, catheter care, care plan updates, and call light system responsiveness. The plan includes staff education, audits, and policy reviews to ensure compliance.

The visit was triggered by complaints #58992 and #59731. The complaint was substantiated as the facility failed to meet wireless call system requirements and timely response to resident call lights.

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. Residents reported delays in call light responses and staff interviews confirmed inconsistent pager use and lack of guidance on locating residents.

All deficiencies previously reported on the CMS-2567 were corrected as of 08/11/2011, with no uncorrected deficiencies remaining at the time of this revisit.

The inspection included a complaint investigation (#48608) related to resident rights, care planning, infection control, and safety.

The facility was found deficient in multiple areas including failure to properly assess and provide for residents' needs related to restraints, choice, discharge planning, comprehensive assessments, care planning, personal hygiene, accident hazards, medication monitoring, food sanitation, and infection control.

The facility developed and implemented corrective actions to ensure compliance with regulations, including posting the survey report, posting the Emergency Management Plan, and securing chemical storage.

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

The facility identified deficiencies related to timely completion and updating of Functional Capacity Screens, Negotiated Service Agreements, and Health Service Plans for residents with significant changes in condition. Corrective actions include staff education, tracking systems, and regular administrative meetings to ensure compliance.

This Plan of Correction addresses deficiencies cited during a complaint investigation survey related to code status and honoring advance directives.

The facility developed and implemented a system to assure correction and continued compliance with regulations, focusing on reviewing residents' advance directives and code status policies following a resident's death.

The plan addresses multiple deficiencies related to staff phone use during resident care, code status documentation, discharge documentation, hospitalization notifications, bed hold policy, timely completion of discharge/death MDS, post-dialysis assessments, and medication parameter oversight.

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

The facility had deficiencies related to food temperature control and kitchen sanitation. Corrective actions include staff education, calibration of thermometers, removal of salad bar, replacement of oven, and implementation of cleaning and sanitation logs.

The Plan of Correction outlines corrective actions including staff education and audits to ensure compliance with resident rights, care plan revisions, restorative services, infection control, and medication management policies.