Inspection Reports for
Lakeview Village
13840 W 91ST TERR, LENEXA, KS, 66215-3374
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
95% occupied
Based on a January 2013 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 8, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the initial survey conducted on 2013-01-15.
Findings
The revisit confirmed that all previously cited deficiencies identified by regulation numbers 483.10(b)(5)-(10), 483.10(b)(1), 483.20(d), 483.20(k)(1), and 483.60(b),(d),(e) were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Feb 8, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the initial survey conducted on 2013-01-15.
Findings
The revisit confirmed that all previously identified deficiencies related to regulations 483.10(b)(5)-(10), 483.10(b)(1), 483.20(d), 483.20(k)(1), and 483.60(b), (d), (e) were corrected as of 2013-02-08.
Deficiencies (3)
Regulation 483.10(b)(5)-(10), 483.10(b)(1) deficiencies were corrected by 02/08/2013.
Regulation 483.20(d), 483.20(k)(1) deficiencies were corrected by 02/08/2013.
Regulation 483.60(b), (d), (e) deficiencies were corrected by 02/08/2013.
Inspection Report
Re-Inspection
Census: 150
Deficiencies: 3
Date: Jan 15, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with regulatory requirements following a prior survey.
Findings
The facility failed to provide required Liability Notice and Beneficiary Appeal Rights Review documentation for several residents, failed to develop a comprehensive individualized care plan for activities for one resident, and failed to properly label and store medications on medication carts.
Deficiencies (3)
F 156: The facility failed to provide a Liability Notice and Beneficiary Appeal Rights Review for resident #286 and failed to document the reason for discharge and skilled services for four residents receiving skilled Medicare services.
F 279: The facility failed to develop a comprehensive individualized care plan for activities for resident #273, omitting activity preferences identified in the assessment.
F 431: The facility failed to date insulin pens upon opening and failed to properly store and label medications on two medication carts, including undated insulin pens and an unlabeled medication cup.
Report Facts
Resident census: 150
Residents sampled for Liability Notice review: 5
Residents sampled for care plan review: 29
Medication carts inspected: 4
Medication carts with deficiencies: 2
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jan 15, 2013
Visit Reason
The document is a Plan of Correction responding to deficiencies cited during the annual survey completed on January 15, 2013, at Lakeview Village.
Findings
The plan addresses multiple deficiencies including notification for Medicare non-coverage, provision of resident activities, and proper medication storage and labeling. Corrective actions and prevention measures have been implemented with specified completion dates.
Deficiencies (4)
F0000: Facility-wide systems were developed to assure correction and continued compliance with Kansas and federal regulations following the annual survey on 1/15/13.
F156-D: Notice of Medicare Non-Coverage was revised to ensure appropriate notification to residents receiving skilled services, with staff instructed to use the new form as of 1/18/13.
F279-D: In-services on providing activities of resident choice were scheduled, and an Activity Cart was created to offer activities 24 hours a day by 2/8/13.
F431-D: Unmarked insulin pens and medication were destroyed; nursing staff received education on proper medication storage and labeling by 2/1/13, with ongoing audits implemented.
Report Facts
Deficiencies cited: 4
Inspection Report
Follow-Up
Deficiencies: 2
Date: Dec 27, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies had been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies previously cited under regulations 483.13(c)(1)(ii)-(iii), (c)(2)-(4) and 483.25(h) were corrected by 12/11/2012.
Deficiencies (2)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4): Previously cited deficiencies were corrected by 12/11/2012.
Regulation 483.25(h): Previously cited deficiency was corrected by 12/11/2012.
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 2
Date: Dec 6, 2012
Visit Reason
The inspection was conducted as a complaint investigation (#KS 62081) related to allegations of mistreatment, neglect, and abuse involving a resident who sustained burns from improper use of a hot pack.
Complaint Details
Complaint investigation #KS 62081 involved allegations of mistreatment, neglect, and abuse related to a resident who received 2nd-3rd degree burns from improper hot pack use. The facility failed to report the incident to the state agency as required.
Findings
The facility failed to report an incident where a resident received 2nd to 3rd degree burns from an unapproved hot pack application. The nursing staff was not trained on hot pack use, and the facility lacked proper policies and guidance for hot pack use, resulting in serious injury and subsequent abscesses requiring hospitalization.
Deficiencies (2)
F225: The facility failed to report allegations of mistreatment and abuse involving a resident who sustained 2nd-3rd degree burns from improper use of a hot pack without a physician's order.
F323: The facility failed to ensure the resident environment was free of accident hazards and failed to provide adequate supervision and guidance on hot pack use, resulting in burns and complications for a resident with impaired sensation.
Report Facts
Resident census: 145
Burn wound measurements: 20.5
Burn wound measurements: 20
Burn wound measurements: 6.3
Burn wound measurements: 2.5
Burn wound measurements: 0.1
Burn wound measurements: 4
Burn wound measurements: 3
Burn wound measurements: 0.1
Hydrocollator temperature: 156
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff D | Licensed Nursing Staff | Applied hot pack without physician order, did not assess resident skin before or after application, not trained on hot pack use |
| Administrative nursing staff C | Administrative Nursing Staff | Revealed nursing staff was not trained on hot pack use and only therapy staff were authorized to use hot packs |
| Licensed nursing staff K | Licensed Nursing Staff | Documented resident's shearing spots and burns, stated lack of training on hot pack use |
| Licensed nursing staff L | Licensed Nursing Staff | Revealed no training or instruction on hot pack use, unaware of facility policy |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 6, 2012
Visit Reason
This Plan of Correction addresses deficiencies cited during a complaint survey completed on 12/6/2012 at Lakeview Village.
Complaint Details
The Plan of Correction responds to deficiencies cited during a complaint survey conducted on 12/6/2012.
Findings
The facility implemented corrective actions including staff training on resident abuse and neglect, restricted access to hydrocollators, and removal of hydrocollators to prevent resident risk. The Plan of Correction aims to assure correction and continued compliance with state and federal regulations.
Deficiencies (2)
F225: Management staff read and signed the Resident Abuse, Neglect and Misappropriation of Resident Property policy and completed annual and remedial training. Investigations of suspected abuse must be reported to the State survey agency within 5 working days.
F323: Resident #1 is no longer in the facility. Hydrocollators were padlocked to restrict nursing staff access and later physically removed to prevent resident risk. Mandatory training on accident hazards was completed by nursing staff.
Report Facts
Date of complaint survey: Dec 6, 2012
Date of Plan of Correction completion: Dec 11, 2012
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 1
Date: Jun 7, 2012
Visit Reason
The inspection was conducted as a complaint investigation (#KS56859) regarding a resident who left the facility unsupervised for over two hours despite wearing a wandering device (wanderguard).
Complaint Details
The visit was triggered by complaint investigation #KS56859. The complaint was substantiated as the facility failed to supervise a wandering resident who left the building undetected for over two hours.
Findings
The facility failed to provide adequate supervision for a cognitively impaired resident at risk for wandering and falls, resulting in the resident leaving the facility unsupervised for over two hours. Multiple staff failed to respond promptly to door alarms and wanderguard alerts, placing the resident in immediate jeopardy. The facility subsequently implemented staff training, system upgrades, and monitoring procedures to address the deficiencies.
Deficiencies (1)
483.25(h) The facility failed to provide adequate supervision for a resident with Alzheimer's dementia who wore a wanderguard and left the facility unsupervised for over two hours, missing scheduled even hour checks. This placed the resident in immediate jeopardy.
Report Facts
Resident census: 111
Fall Risk assessment score: 12
Elopement Assessment score: 14
Number of wanderguard episodes: 6
Alarm activations: 116
Staff trained: 52
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 7, 2012
Visit Reason
This document is a plan of correction submitted by the facility in response to past noncompliance findings.
Findings
The plan of correction addresses past noncompliance issues with compliance training completed on 04/29/2012 and additional training on 05/19/2012. No new deficiencies requiring correction plans were noted.
Deficiencies (2)
F0000 past noncompliance: no plan of correction required. Compliance training was completed on 04/29/2012 and additional training on 05/19/2012.
F323-J past noncompliance: no plan of correction required. Compliance training was provided on 04/29/2012 and additional training completed on 05/19/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 27, 2011
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected.
Findings
The report confirms that all deficiencies previously cited were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 27, 2011
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report shows that all previously cited deficiencies identified by regulation numbers F0156, F0329, F0371, F0425, and F0428 were corrected as of the revisit date.
Inspection Report
Re-Inspection
Census: 142
Deficiencies: 5
Date: Sep 27, 2011
Visit Reason
The inspection was a Health Resurvey to assess compliance with Medicare and Medicaid regulations, including review of medication management, resident rights, food safety, and pharmaceutical services.
Findings
The facility failed to provide individualized Medicare Non-coverage notices with specific reasons for discharge for 3 residents, failed to identify and monitor Black Box Warnings for medications in 3 residents, failed to maintain sanitary food storage and preparation conditions, and failed to date multi-use medication vials. The pharmacist did not report medication irregularities to the attending physician and director of nursing.
Deficiencies (5)
F156: The facility failed to provide individualized Medicare Non-coverage notices with specific reasons for discharge for 3 residents (#25, #103, #168).
F329: The facility failed to identify and monitor Black Box Warnings for medications in 3 residents (#157, #328, #42), including Toprol XL, Abilify, Zyprexa Zydis, and Risperidone.
F371: The facility failed to store, prepare, and serve food under sanitary conditions, including undated and uncovered food items, dirty equipment, and improper thawing practices.
F425: The facility failed to date multi-use medication vials in 1 of 4 medication rooms, including Aplisol Tuberculin and Pneumovax vaccine vials.
F428: The facility pharmacist failed to identify Black Box Warnings for medications and failed to report irregularities to the attending physician and director of nursing for 3 residents (#157, #328, #42).
Report Facts
Resident census: 142
Residents reviewed for unnecessary drugs: 10
Multi-use medication vials undated: 3
Opened undated ice cream cartons: 22
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046007 POC 7ESV11
Visit Reason
This document is a Plan of Correction related to a prior inspection or deficiency report for the facility Lakeview Village.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046007 POC IJLY11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
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