Lakepoint Wichita, LLC

Inspectors wroteThe facility had a census of 79 residents. Based on record review and interviews, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 79 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to use appropriate barriers while sorting soiled laundry, failed to maintain an ongoing waterborne pathogen prevention program to address and mitigate the risk for Legionella (Legionella is a bacterium which can cause pneumonia in vulnerable populations), and failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R)7, R385 and R391. This placed the residents at risk of infectious diseases.

Inspectors wroteThe facility had a census of 79 residents. The sample included 20 residents, with eight reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of the required stop date for Resident (R) 31, R37, R52 and R68s' as-needed (PRN) antianxiety (a class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication. The facility failed to acknowledge and follow up on the CP's request for a diagnosis for R17's Effexor (an antidepressant medication) and Haldol (an antipsychotic medication). This placed the residents at risk for inappropriate or unnecessary use of medications and related side effects.

Inspectors wroteThe facility had a census of 79 residents. The sample included 20 residents, with eight reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a 14-day stop date or specified duration for Resident (R) 31, R37, R52, R68 and R391's ongoing as-needed (PRN) antianxiety (a class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication and failed to get an appropriate diagnosis for R17's Effexor (an antidepressant medication) and Haldol (an antipsychotic medication). This placed the residents at risk for unnecessary medications and related complications.

Inspectors wroteThe facility had a census of 79 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to store and label biologicals as required when staff failed to identify and discard six expired vials of Prevnar (a vaccine that protects against 20 different strains of the Streptococcus pneumoniae bacteria) in one of three medication rooms. The facility further failed to place an open date on insulin (a hormone that lowers the level of glucose in the blood) pens in one of three treatment carts. This placed the affected residents at risk of receiving an expired and ineffective dose of Prevnar and insulin.

Inspectors wroteThe facility had a census of 79 residents. The sample included 20 residents, with two reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote dignity for Resident (R)29, when staff referred to the resident as a feeder and stood to assist the resident with her meal. This placed R29 at risk for impaired dignity.

Inspectors wroteThe facility had a census of 79 residents. The sample included 20 residents with three residents reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the CMS Form 10055, Advanced Beneficiary Notice (ABN), to the resident or their representative for Resident (R) 429. This placed the residents at risk for uninformed decisions regarding skilled services.

Inspectors wroteThe facility had a census of 79 residents. The sample included 20 residents, with one reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to notify the State Long Term Care Ombudsman (LTCO) for Resident (R) 31's facility-initiated discharge to the hospital. This placed R31 at risk for impaired rights.

Inspectors wroteThe facility had a census of 79 residents. The sample included 20 residents. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards when staff left a container of toilet bowl cleaner, a container of Comet, two aerosol spray deodorants, and a container of Virex in an unlocked wooden cabinet. This placed the two cognitively impaired, independently mobile residents at risk for preventable accidents or injuries.

Inspectors wroteThe facility had a census of 79 residents. The sample included 20 residents in which two residents were reviewed for urinary tract infections (UTI-an infection in any part of the urinary system). Based on observation, record review, and interview, the facility failed to provide services consistent with the standards of care for Resident (R) 7's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). This placed R7 at risk for catheter-related complications and UTI.

Inspectors wroteThe facility had a census of 79 residents. The sample included 20 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment and develop a trauma-informed plan of care for Resident (R) 52 and R71, who had a diagnosis of post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the residents at risk for unmet behavioral and mental health needs.

Inspectors wrote- The Electronic Medical Record (EMR) for R31 documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteomyelitis (local or generalized infection of the bone and bone marrow), pain, atrial fibrillation (rapid, irregular heartbeat), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition and was dependent upon staff for transfers. R31 required substantial assistance with toileting, showers, dressing, and mobility, and was independent with transfers. [...]

Inspectors wroteThe facility census totaled 88 residents, with three residents in the sample and reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment for one resident by the failure to implement interventions to prevent repeated falls with major injury for Resident (R) 2, who had a fall that resulted in a fractured wrist.

Inspectors wroteThe facility reported a census of 60 residents with four residents selected for review for activity of daily living (ADL's). Based on observation, interview, and record review, the facility failed to ensure bathing opportunities as per resident preference for three residents (R) 1, R2, and R3 of the four residents reviewed for activities of daily living.

Inspectors wroteThe facility reported a census of 60 residents with five residents selected for review, which included three residents reviewed for unnecessary medication administration. Based on observation, interview, and record review, the facility failed to administer one resident's (R)3 Percocet (narcotic pain medication), and Metformin (a medication used to lower blood sugar), cyclobenzaprine (a muscle relaxer), doxycycline and cefdinir (antibiotics) as ordered by the physician.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with eight residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure residents remained free from avoidable accidents and injuries. On 01/06/23 staff transferred Resident (R) 38 but failed to use appropriate gait belt technique. This failure resulted in a fall with a femur (thigh bone) fracture, which required surgical repair. The facility also failed to ensure adequate supervision during toileting for R10, who had a non-injury fall as a result. The facility further failed to ensure R14's bed was left in a safe position which placed R14 at increased risk for falls and related injury.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with four residents reviewed for nutrition. Based on observation, record review, and interview, the facility failed to identify and respond to weight loss for Resident (R)14 to prevent further loss. The facility failed to ensure R14 had the required built-up eating utensils and staff assistance during meals and failed to involve the registered dietician (RD) and R14's physician to evaluate and initiate interventions to prevent further loss. This deficient practice resulted in a significant weight loss of 12.59 percent (%) over six months (August 2022 to February 2023) for R14 and placed this resident at risk for other adverse effects.

Inspectors wroteThe facility identified a census of 58 residents. Based on record review, and interviews, the facility failed to ensure the staff person designated as the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention and Control Program, completed specialized training in infection prevention and control. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections.

Inspectors wroteThe facility identified a census of 48 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to ensure Residents (R)7, R9, R35, and R42 received care in a dignified manner during meal service. The facility additionally failed to ensure R30, R48, and R50 received assistive cares in a dignified manner during basic cares and interactions. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - On 03/06/23 at 12:02AM R32 (a totally dependent severely cognitively impaired resident) was in the dining room waiting for breakfast. R32 was making cooing sounds and chewing on her blanket. Staff abruptly stated, stop being silly to R32 and pulled the blanket away from her mouth. R32 did not have her doll with her. At 12:45AM R32's food arrived. [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to maintain a homelike environment. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - On 03/06/23 at 07:00AM an inspection of the facility's kitchen and dining service was completed. Observation of the breakfast and lunch service on 03/06/23 and for both breakfast and lunch for the duration of the survey revealed the residents received their room trays served in Styrofoam plate (boxes) with plastic silverware and disposable cups. On 03/08/23 at 10:51AM Dietary Staff BB stated the facility currently did not have a insulated food delivery cart to keep the trays warm so the kitchen used the Styrofoam plates for residents eating in their rooms. [...]

Inspectors wroteThe facility identified a census of 58 residents. Based on observation, record review, and interviews, the facility failed to provide consistent weekend activities. This deficient practice placed the residents at risk for complications related to decreased psychosocial wellbeing. Findings Included: - On 03/07/23 at 02:30PM Activities Staff Z provided staff-led Bingo for the residents in the 900 hallway recreation room. A review of the facility's Activities Calendar for February 2023 indicated for the weekend dates of the 4th, 5th, 26th revealed no activities provided to the residents. A review of the calendars for January, February, and March of 2023 revealed the facility heavily scheduled television related activities on the weekend. On 03/07/23 at 03:20PM Resident Council members reported that the facility does not provide activities for residents every weekend. [...]

Inspectors wroteThe facility identified a census of 58 residents. Based on observation, record review, and interviews, the facility failed to provide a certified activity professional to ensure supervision of activities, delegation of activities to weekend staff and monitoring of the activities program to ensure it met the needs of the residents. This deficient practice placed the residents at risk for complications related to decreased psychosocial wellbeing. Findings Included: - On 03/07/23 at 02:30PM Activities Staff Z provided staff-led Bingo for the residents in the 900 hallway recreation room. A review of the facility's Activities Calendar for February 2023 indicated for the weekend dates of the 4th, 5th, and 26th revealed no activities provided to the residents. [...]

Inspectors wroteThe facility identified a census of 58 residents and two medication rooms. Based on observation, record review, and interview, the facility failed to properly date and/or discard two individual opened vials of tuberculin (a sterile protein used in a test by injection for infection with or immunity to tuberculosis [TB-a bacterial infection of the lungs]). This deficient practice left the residents being administered the tuberculin at risk for adverse effects or less effective TB screening.

Inspectors wroteThe facility identified a census of 58 residents and one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food handling and storage. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns Findings Included: - On 03/06/23 at 07:00AM an initial walk-through of the kitchen was completed. The walk-through revealed the spice rack storage area was dusty from the used spice containers. On 03/06/23 at 11:50AM staff were in the dining room preparing to serve lunch to the residents. The ice machine's scoop was left in the ice bin in the service area. On 03/07/23 at 07:30AM three Styrofoam food trays sat on top of the food service station. [...]

Inspectors wroteThe facility identified a census of 58 residents. Based on observation, and interviews, the facility failed to maintain adequate infection control practices when staff failed to store oxygen tubing in a sanitary manner and failed to disinfect a shared glucometer (device used to measure blood glucose levels) after use. The facility further failed to ensure sharps (needles devices to break the skin) were disposed of in a safe, sanitary manner to prevent infections related to needle stick accidents. This deficient practice placed the affected residents at increased risk for the spread of pathogens and infections.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with five reviewed for vaccination status. Based on record reviews, and interviews, the facility failed to obtain influenza (highly contagious viral infection that attacks the lungs, nose, and throat and can be deadly in high-risk groups) vaccination and pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) vaccination consents, declinations or administration information for Resident (R) 38, R32, R45 and R26. This placed the residents at increased risk for influenza, pneumonia, and related complications.

Inspectors wroteThe facility identified a census of 58 residents with 15 residents included in the sample. The facility identified eleven residents who discharged from Medicare Part A services . Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) and Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123 which contained the required information and within the required timeframes for Resident (R) 24 and R261. This failure placed the residents at risk for decreased autonomy and impaired right to appeal.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with three residents sampled for hospitalization/transfer. Based on observation, record review, and interview, the facility failed to provide written notice of transfer with the required information to Resident (R) 3 and R38 or to their family/durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) in a practicable amount of time. This deficient practice had the risk of miscommunication between facility and resident/family and possible missed opportunity for healthcare service for R3 and R38.

Inspectors wroteThe facility identified a census of 58 residents. The sample include 15 residents. Based on record review, observations, and interviews, the facility failed to transmit Resident (R) 41's discharge Minimum Data Set (MDS) within the required timeframe. Findings Included: - The Medical Diagnosis section within R41's Electronic Medical Records (EMR) included diagnoses of coronary artery disease (abnormal condition that may affect the flow of oxygen to the heart), hypertension (high blood pressure), hepatitis (inflammatory condition of the liver), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), lung cancer, and respiratory failure. A review of R41's EMR revealed he admitted to the facility on [DATE] and passed away at the facility on 11/06/22. [...]

Inspectors wroteThe facility reported a census of 58. The sample included 15 with 15 residents review for care plan revision. Based on observation, record review, and interviews, the facility failed to revise the fall care plan with interventions for Resident (R) 10. The facility further failed to revise the plan of care with dementia (progressive mental disorder characterized by failing memory, confusion) related interventions for R9, R32, and R18. This deficient practice placed both residents at risk for impaired ability to achieve and/or maintain their highest practicable level of physical and emotional wellbeing due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with seven residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 18 was assisted with his hearing aids. This deficient practice placed R18 at risk of difficulty with communication, possible isolation and decline in cognition.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with seven residents reviewed for activities of daily living (ADLs) cares. Based on observation, record review, and interview, the facility failed to ensure bathing was provided for two residents who required assistance from staff to complete the care. This deficient practice placed resident (R)18 and R15 at risk for impaired psychosocial wellbeing, potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with five residents sampled for positioning. Based on observation, record review, and interview, the facility failed to ensure staff consistently provided care to R14 to help maintain bed mobility/positioning, and assistance with eating. This placed R14 at increased risk for a decline in range of motion and decreased independance.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to provide consistent dementia care and services for Residents (R)9 and R32. This deficient practice placed both residents at risk for impaired ability to achieve and/or maintain their highest practicable level of physical and emotional wellbeing.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with five residents reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for physician ordered antihypertensive (class of medication used to treat high blood pressure) medication was administered outside physician ordered parameters for Resident (R) 18 and R26. This placed the affected residents at risk for unnecessary medication and possible side effects or complications.

Inspectors wrote- R18's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of need for assistance with personal care, atrial fibrillation (rapid, irregular heartbeat), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin, dementia (progressive mental disorder characterized by failing memory, confusion), angina (chest pain), and hypertension (elevated blood pressure). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented that R18 required limited assistance of one staff member for ADLs. The MDS documented R18 required physical assistance with bathing with no set assistance during the look back period. [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the physician documented an appropriate clinical indication for antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) for Resident (R) 18. This deficient practice placed these resident at risk for the potential of unnecessary psychotropic (altering mood or thoughts) medication administration thus leading to possible harmful side effects.

Inspectors wroteThe facility census totaled 58 residents with 15 residents in the sample; all were reviewed for Minimum Data Set (MDS) completion. Based on record review and interview, the facility failed to complete the required Discharge or Death MDSs in a timely manner for the discharges of resident (R)7, R1, R6, and R2, and the deaths of R4 and R3.

Inspectors wroteThe facility census totaled 58 residents, with 15 residents in the sample. Based on observation, interview, and record review, the facility failed to treat Resident (R) 9 with dignity and respect when a Certified Nurse Aid (CNA) used her personal phone, scrolled on personal social media, but did not engage with the resident she assisted with eating during dinner service.

Inspectors wroteThe facility census totaled 58 residents, with 15 residents in the sample. Based on observation, interview, and record review, the facility failed to ensure that Residents (R) 47 and R267 had Advanced Directives/Code Status noted on the physical chart or on the Electronic Medical Record (EMR), which could have resulted in a resident receiving Cardiopulmonary Resuscitation (CPR) in the event of resident demise instead of the Do Not Resuscitate (DNR) as requested.

Inspectors wroteThe facility census totaled 58 residents, with 15 residents included in the sample and one resident reviewed for discharge. Based on interview and record review, the facility failed to document the required discharge information in Resident (R) 67's medical record.

Inspectors wroteThe facility census totaled 58 residents, with 15 residents included in the sample and one resident looked at for hospitalizations. Based on interview and record review, the facility failed to provide Resident (R) 6 or their representative a written notice for hospitalization.

Inspectors wroteThe facility census totaled 58 residents, with 15 residents included in the sample and one resident looked at for hospitalizations. Based on interview and record review, the facility failed to provide Resident (R) 6 or their representative with a bed-hold policy upon transfer to a hospital.

Inspectors wroteThe facility census totaled 58 residents, with 15 residents included in the sample and one resident reviewed for discharge. Based on interview and record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-and post-discharge medications, and develop a post-discharge plan of care, including discharge instructions for Resident (R) 67.

Inspectors wroteThe facility census totaled 58 residents, with 15 included in the sample. One resident was reviewed for dialysis (the clinical purification of blood, as a substitute for the normal function of the kidney). Based on interview, observation, and record review, the facility failed to provide the necessary care and service to attain or maintain a resident's highest practicable physical well-being related to dialysis by not documenting assessments of Resident (R) 46's dialysis fistula (connection made by a vascular surgeon, of an artery to a vein) site.

Inspectors wroteThe facility reported a census of 58 residents, with 15 sampled and five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to follow the physician orders for hypertensive medications for Resident (R)49 and R11 and the facility failed to provide parameters for blood glucose (BG; blood sugar) for R49.