A list of the most recent deficiencies for Lakepoint Wichita, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-27 | 2023-10-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-27 | 2023-10-17 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-05 | 2023-06-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-09 | 2023-04-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-09 | 2023-04-21 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-09 | 2023-04-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-09 | 2023-04-21 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-03-09 | 2023-04-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-09 | 2023-04-21 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-09 | 2023-04-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-09 | 2023-04-21 | N |
| Provide activities to meet all resident's needs. | Health | 2023-03-09 | 2023-04-21 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-03-09 | 2023-04-21 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-03-09 | 2023-04-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-04-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-09 | 2023-04-21 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-03-09 | 2023-04-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-03-09 | 2023-04-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-09 | 2023-04-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-09 | 2023-04-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-09 | 2023-04-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-09 | 2023-04-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-09 | 2023-04-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-03-09 | 2023-04-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-09 | 2023-04-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-20 | 2022-05-13 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-04-20 | 2022-05-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-20 | 2022-05-13 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-25 | 2021-09-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-25 | 2021-09-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-25 | 2021-09-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-08-25 | 2021-08-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-22 | 2021-08-18 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-07-22 | 2021-08-18 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-07-22 | 2021-08-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-22 | 2021-08-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-07-22 | 2021-08-18 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-07-22 | 2021-08-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-22 | 2021-08-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-22 | 2021-08-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-22 | 2021-08-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-25 | 2019-10-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-25 | 2019-10-25 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-09-25 | 2019-10-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-25 | 2019-10-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-25 | 2019-10-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-25 | 2019-10-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-25 | 2019-10-25 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-09-25 | 2019-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-25 | 2019-10-25 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-04 | 2019-10-04 | N |
