Cycle 1
Health 2024-12-04 · Fire 2024-12-04
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Wichita, KS
Lakepoint Wichita, LLC
2-star overall rating with 2-star inspections with $18,342 in total fines with 12 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
1315 N West Street, Wichita, KS
(316) 943-1295
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-07-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.20
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.76
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.20
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
5.16
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,156
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.73% · Performance 21.37% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.25% · Performance 7.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
4.10
Baseline 3.60 hours · Performance 4.24 hours · Measure score 4.10 · Achievement 4.10 · Improvement 2.43
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 10.67% · Lower 95% interval 7.33% |
| Discharge to community | 36.62% |
50.57%
14 pts worse
|
Worse than the National Rate · Eligible stays 48 · Observed rate 25% · Lower 95% interval 24.33% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 106 · Denominator 106 |
| Falls with major injury | 0.94% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 106 |
| Discharge self-care score | 56.41% |
53.69%
2.7 pts better
|
Numerator 44 · Denominator 78 |
| Discharge mobility score | 46.15% |
50.94%
4.8 pts worse
|
Numerator 36 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 1.9% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 105 · Adjusted rate 1.52% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 10% · Lower 95% interval 5.03% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 152 |
| Staff flu vaccination coverage | 34.21% |
42%
7.8 pts worse
|
Numerator 65 · Denominator 190 |
| Discharge function score | 61.54% |
56.45%
5.1 pts better
|
Numerator 48 · Denominator 78 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 97.56% |
96.28%
1.3 pts better
|
Numerator 40 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 10.2% |
25.2%
15 pts worse
|
Numerator 5 · Denominator 49 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.0 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.2
0.6 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
4.4%
0.2 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.4% · Q3 5.1% · Q4 5.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
5.6%
2.9 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.6% · Q3 3.6% · Q4 1.7% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
5.0%
1.9 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.9% · Q3 4.0% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.7% |
23.2%
0.5 pts better
|
19.6%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 23.5% · Q3 23.1% · Q4 20.4% · 4Q avg 22.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
19.8%
6.5 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 15.4% · Q3 13.5% · Q4 10.5% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.6% |
18.4%
3.2 pts worse
|
16.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 21.3% · Q3 23.6% · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
18.8%
6.9 pts better
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 16.3% · Q3 14.0% · Q4 8.5% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.8%
0.3 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.9% · Q3 0.0% · Q4 1.3% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.5% |
3.1%
3.4 pts worse
|
1.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.1% · Q3 8.8% · Q4 5.3% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
23.2%
7.2 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 11.9% · Q3 17.4% · Q4 16.4% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
4.6%
1.8 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 5.9% · Q3 5.0% · Q4 6.4% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
75.6%
23.2 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
11.7%
2.5 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 14.9% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
2.2%
0.7 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
73.5%
25.7 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.4% |
23.0%
10.6 pts better
|
23.9%
11.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 11.9% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-09 · Fire 2023-03-09
23 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-07-22 · Fire 2021-07-22
11 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-04
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-12-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-21
E · Potential for more than minimal harm
2024-12-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-21
F · Potential for more than minimal harm
2023-03-09
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-06-14
F · Potential for more than minimal harm
2023-03-09
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-06-14
F · Potential for more than minimal harm
2023-03-09
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-06-14
F · Potential for more than minimal harm
2023-03-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-14
F · Potential for more than minimal harm
2023-03-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-14
F · Potential for more than minimal harm
2023-03-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-14
F · Potential for more than minimal harm
2023-03-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-14
F · Potential for more than minimal harm
2023-03-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-14
F · Potential for more than minimal harm
2023-03-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-14
F · Potential for more than minimal harm
2023-03-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-14
E · Potential for more than minimal harm
2023-03-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-03-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-14
F · Potential for more than minimal harm
2021-07-22
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-08-25
F · Potential for more than minimal harm
2021-07-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-03
F · Potential for more than minimal harm
2021-07-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-09-03
D · Potential for more than minimal harm
2021-07-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-09-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-04
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-01-03
F · Potential for more than minimal harm
2024-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-04
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-12-04
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-04
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-04
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-04
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-04
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-07-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-30
D · Potential for more than minimal harm
2023-09-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-17
D · Potential for more than minimal harm
2023-09-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-17
G · Actual harm
2023-03-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-21
G · Actual harm
2023-03-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-03-09
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-09
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-09
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-09
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-09
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-04-21
E · Potential for more than minimal harm
2021-07-22
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2021-08-18
D · Potential for more than minimal harm
2021-07-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-08-18
D · Potential for more than minimal harm
2021-07-22
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-18
D · Potential for more than minimal harm
2021-07-22
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-18
D · Potential for more than minimal harm
2021-07-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-08-18
D · Potential for more than minimal harm
2021-07-22
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-18
D · Potential for more than minimal harm
2021-07-22
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2021-08-18
D · Potential for more than minimal harm
2021-07-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-08-18
D · Potential for more than minimal harm
2021-07-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-08-18
Penalties and ownership
What sits behind the stars
$13,762
2023-04-17
Fine
Fine · fine $13,762
Fine
$4,580
2023-03-20
Fine
Fine · fine $4,580
Fine
Ownership
Harrison, Warner
5% Or Greater Direct Ownership Interest · Individual
Lakepoint By Axiom, LLC
5% Or Greater Direct Ownership Interest · Organization
Barbeau, Brian
Operational/Managerial Control · Individual
Barbeau, Brian
Corporate Director · Individual
Becnel, Chance
Operational/Managerial Control · Individual
Becnel, Chance
Corporate Director · Individual
Harrison, Warner
Operational/Managerial Control · Individual
Harrison, Warner
Corporate Director · Individual
Kruse, Brenda
Corporate Officer · Individual
Lakin, Gregory
Operational/Managerial Control · Individual
Lakin, Gregory
Corporate Director · Individual
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