Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakepoint Wichita, Llc during CMS and state inspections, most recent first.
The facility failed to submit accurate staffing information through the PBJ, as required by CMS, indicating low weekend staffing and missing RN hours for several days. A review showed appropriate staffing, and an administrative nurse suggested previous owners' incorrect submissions might be the cause. The facility's policy requires accurate staffing data submission, distinguishing between employees and agency workers, at least quarterly. This failure placed residents at risk for inadequate staffing.
The facility failed to use appropriate barriers for soiled laundry, lacked a waterborne pathogen prevention program, and did not implement Enhanced Barrier Precautions (EBP) for residents with specific conditions. Staff did not use gowns during high-contact care, and there was no documentation of a water management plan, increasing the risk of infection transmission.
The facility failed to ensure the Consultant Pharmacist identified and reported missing stop dates for PRN antianxiety medications for several residents, and did not respond to requests for a diagnosis for a resident's use of Effexor and Haldol. This oversight placed residents at risk for inappropriate medication use.
The facility failed to ensure that PRN psychotropic medications for several residents had a 14-day stop date or specified duration, as required by policy. This oversight was observed in residents prescribed antianxiety medications like Ativan and hydroxyzine without a stop date or physician's rationale for extended use. Additionally, some residents were prescribed medications like Effexor and Haldol without appropriate diagnoses, placing them at risk for unnecessary adverse side effects.
The facility failed to discard expired Prevnar vaccine vials and did not date insulin pens for several residents, risking ineffective medication administration. Staff confirmed the presence of expired vials and the lack of open dates on insulin pens, which violated the facility's Medication Storage and Labeling policy.
A resident with dementia and other conditions was referred to as a 'feeder' by staff, and assistance with meals was provided while standing, which was deemed undignified. The facility's policy on resident rights was not upheld, leading to a deficiency in maintaining the resident's dignity.
A facility failed to provide a resident with the CMS Form 10055, Advanced Beneficiary Notice (ABN), when their skilled services ended. The ABN, which informs beneficiaries about potential Medicare non-coverage and financial responsibility, was not given, leading to uninformed decisions. Administrative staff acknowledged the oversight, and the facility lacked an ABN policy.
A facility failed to notify the State Long Term Care Ombudsman of a resident's discharge to the hospital, as required by policy. The resident, who had multiple medical conditions and required assistance with daily activities, was found unresponsive with low blood sugar, leading to a hospital transfer. The responsible staff member was no longer employed, and the administrative nurse acknowledged the oversight.
Hazardous chemicals, including toilet bowl cleaner and Comet, were found unsecured in an unlocked cabinet in a facility, posing a risk to two cognitively impaired, independently mobile residents. The facility's policy required such chemicals to be stored in a locked area, which was not followed.
A resident with multiple sclerosis and a neurogenic bladder did not receive proper urinary catheter care, leading to a deficiency. Observations showed a CNA did not use a gown during care, and the catheter tubing was often on the floor, risking contamination. The facility failed to implement Enhanced Barrier Precautions due to misunderstanding, despite care plans and physician orders outlining necessary procedures.
The facility failed to complete trauma-informed care assessments and develop care plans for two residents with PTSD, depression, and anxiety. Both residents' care plans lacked interventions to identify triggers and prevent re-traumatization. Staff interviews revealed a lack of awareness about the residents' PTSD and the necessary assessments, despite the facility's policy emphasizing trauma-informed care.
The facility failed to coordinate care between the facility and hospice providers for two residents receiving hospice services. Both residents' care plans lacked specific instructions on hospice services, such as support visits, supplies, and medications. This deficiency was confirmed by the facility's administrative nurse and nurse consultant, placing the residents at risk for inadequate end-of-life care.
A resident with multiple health issues and cognitive impairment experienced repeated falls, including one resulting in a fractured wrist, due to inadequate interventions and lack of a comprehensive fall prevention plan. Despite being at high risk for falls, the facility failed to implement effective measures, such as a toileting schedule or consistent monitoring, to prevent these incidents.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required by the Centers for Medicare & Medicaid Services (CMS). The PBJ report for Fiscal Year 2023 Quarter 4 and Fiscal Year 2024 Quarter 1 indicated excessively low weekend staffing and a lack of Registered Nurse (RN) hours for several days in January, February, and March 2024. However, a review of the facility's records showed appropriate weekend staffing and RN coverage on the specified dates. An administrative nurse suggested that the discrepancy might be due to incorrect submissions by the previous company owners. The facility's policy mandates the submission of accurate staffing data, including the category of work for each direct care staff member, distinguishing between employees and agency or contract workers, and submitting this data to CMS at least quarterly. The failure to submit accurate PBJ data placed residents at risk for unidentified and ongoing inadequate staffing.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to use appropriate barriers while handling soiled laundry, which could lead to cross-contamination between soiled and clean laundry. Maintenance Staff U confirmed that laundry staff only used gloves without wearing a barrier gown or apron while sorting soiled laundry. This practice was contrary to the facility's policy, which required the use of personal protective equipment to prevent the spread of infection. The facility also did not maintain an ongoing waterborne pathogen prevention program to address and mitigate the risk of Legionella. Maintenance Staff U reported that the procedure involved flushing toilets and running faucets and showers weekly in areas with fewer residents, but there was no documentation or evidence of a water management plan. This lack of documentation and monitoring placed residents at risk of contracting Legionella pneumonia. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for three residents with conditions requiring such precautions. Observations revealed that staff did not use gowns during high-contact care activities, such as handling gastrostomy tubes and urinary drainage bags. Interviews with staff indicated a lack of understanding regarding EBP requirements, and there were no EBP signs or PPE available in the residents' rooms. This failure to implement EBP increased the risk of infection transmission among residents.
Failure to Ensure Proper Medication Management and Communication
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported the absence of required stop dates for as-needed (PRN) antianxiety medications for several residents, including R31, R37, R52, and R68. These medications, such as Ativan and hydroxyzine, were prescribed without a specified end date, which is a critical oversight in medication management. The CP's monthly medication regimen reviews for these residents did not include any recommendations or alerts regarding the missing stop dates, which is a deviation from the facility's Medication Administration policy. Additionally, the facility did not respond to the CP's request for a diagnosis for R17's use of Effexor and Haldol. Despite the CP's repeated requests for an update on the diagnosis for these medications, the facility's records lacked a physician's response or rationale for their continued use. This oversight placed R17 at risk for inappropriate use of psychotropic medications without a clear medical justification. The facility's failure to adhere to its own policies regarding medication regimen reviews and communication of findings to the physician or prescriber resulted in multiple residents being at risk for inappropriate or unnecessary medication use. The lack of stop dates and unaddressed CP recommendations highlight significant gaps in the facility's medication management processes, potentially leading to adverse effects for the residents involved.
Failure to Ensure Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed on an as-needed (PRN) basis for several residents had a 14-day stop date or specified duration, as required by their policy. This oversight was observed in the cases of multiple residents who were prescribed antianxiety medications such as Ativan and hydroxyzine without a stop date or physician's rationale for extended use. For instance, one resident with diagnoses including depression and anxiety was prescribed Ativan without a stop date, placing them at risk for adverse medication side effects. Similarly, another resident with severe cognitive impairment was prescribed Ativan for restlessness without a stop date, despite exhibiting behaviors that could potentially be managed with non-pharmacological interventions. Additionally, the facility did not obtain appropriate diagnoses for the use of certain psychotropic medications for some residents. One resident was prescribed Effexor and Haldol without documented physician diagnoses or rationale for their continued use. This lack of documentation and oversight in medication management placed the resident at risk for unnecessary adverse side effects. The facility's policy required that psychotropic medications be accompanied by a qualifying diagnosis and a list of specific target behaviors to be monitored, which was not adhered to in these cases. The facility's failure to adhere to its psychotropic medication policy, which mandates a 14-day stop date for PRN medications and requires a physician's rationale for continued use, resulted in several residents being at risk for unnecessary medication side effects. The lack of proper documentation and monitoring of these medications, as well as the absence of non-pharmacological interventions, contributed to the deficiencies identified during the survey.
Failure to Properly Store and Label Biologicals and Insulin Pens
Penalty
Summary
The facility failed to properly store and label biologicals, specifically by not discarding six expired vials of Prevnar vaccine in one of the medication rooms. During an observation, it was noted that these vials had an expiration date of August 2024, yet they were still present in the medication room in December 2024. Licensed Nurse K confirmed the presence of the expired vials and acknowledged that expired medications should be placed in a designated bin for destruction by the pharmacy. Administrative Nurse D also verified that expired medications should be disposed of appropriately, as per the facility's Medication Storage and Labeling policy. Additionally, the facility did not place open dates on insulin pens for several residents, which is a requirement for ensuring the effectiveness of the medication. Observations revealed that insulin pens for multiple residents lacked open and discard dates. Licensed Nurse J confirmed these findings and stated that staff should date insulin pens when opened. Administrative Nurse D reiterated the expectation for staff to place open dates on insulin pens. The failure to date these insulin pens was contrary to the facility's policy and placed residents at risk of receiving ineffective doses of insulin.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to promote dignity for a resident, identified as R29, when staff referred to her as a 'feeder' and stood while assisting her with meals. R29, who had diagnoses including dementia, major depressive disorder, delusional disorder, anxiety, and hypertension, was dependent on staff for various activities, including eating. Observations revealed that a Certified Nurse Aide (CNA) referred to the dining area as the 'feeder table' and mentioned that residents who required assistance with eating were seated there. This language and approach were deemed undignified. Additionally, it was observed that a CNA stood beside R29 while assisting her with eating, which was addressed by administrative staff as a dignity issue. The facility's Resident Rights policy emphasized the right to a dignified existence and self-determination, which was not upheld in this instance. The actions of the staff, including the use of undignified language and standing while assisting with meals, contributed to the deficiency in maintaining and enhancing the resident's dignity and respect.
Failure to Provide Advanced Beneficiary Notice
Penalty
Summary
The facility failed to provide the CMS Form 10055, Advanced Beneficiary Notice (ABN), to a resident, identified as R429, or their representative when the resident's skilled services ended. This oversight was discovered during a review of the resident's clinical record, which lacked evidence of the ABN being provided. The ABN form is crucial as it informs beneficiaries that Medicare may not cover future skilled therapy and outlines the options available to them, including the potential financial responsibility if Medicare does not pay. The absence of this form placed the resident at risk for making uninformed decisions regarding their skilled services. Administrative Staff B admitted to contacting R429's representative by phone when it was time for the resident to be discharged from skilled care. During this conversation, the representative expressed a desire for the resident to remain in the facility for a few more days due to a family death. Although the staff member informed the representative about the increase in room price, they failed to provide the necessary information on the ABN form CMS 10055. This was confirmed by Administrative Staff A, who verified that the ABN was not provided. Additionally, the facility was unable to produce an ABN policy upon request, further highlighting the deficiency in their process.
Failure to Notify LTCO of Resident's Hospital Discharge
Penalty
Summary
The facility failed to notify the State Long Term Care Ombudsman (LTCO) of a facility-initiated discharge of a resident, identified as R31, to the hospital. R31 had a range of medical conditions, including depression, anxiety, osteomyelitis, pain, atrial fibrillation, and peripheral vascular disease. The resident was documented to have intact cognition and required substantial assistance with daily activities. On a specific date, a nurse found R31 unresponsive with a low blood sugar level, prompting the family to request hospital evaluation. However, the facility's records lacked documentation of notifying the LTCO about this discharge. Interviews with facility staff revealed that the social service personnel responsible for notifying the LTCO was not employed at the time of R31's discharge, and the administrative nurse confirmed that the notification should have been sent. The facility's policy required notifying the LTCO of any facility-initiated transfer or discharge at the same time the resident or their representative was informed. The failure to notify the LTCO was a breach of this policy, placing the resident at risk for impaired rights.
Hazardous Chemicals Found Unsecured in Facility
Penalty
Summary
The facility failed to ensure an environment free from accident hazards by leaving hazardous chemicals in an unlocked wooden cabinet. During an observation, it was found that the cabinet contained a container of toilet bowl cleaner, a container of Comet, two aerosol spray deodorants, and a container of Virex. These items were accessible in the 200-hall quiet area near the visitor bathroom, posing a risk to two cognitively impaired, independently mobile residents. The labels on these products indicated that they could cause harm if ingested, inhaled, or if they came into contact with skin or eyes. Maintenance Staff verified the presence of these chemicals in the unlocked cabinet and acknowledged that they should have been stored in a locked housekeeping cart. The facility's Chemical Storage Policy, revised earlier in the year, required that all hazardous chemicals be stored in a locked area or used under supervision. The failure to adhere to this policy placed the residents at risk for preventable accidents or injuries.
Deficiency in Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a deficiency in maintaining standards of care. The resident, who had multiple sclerosis and a neurogenic bladder, was dependent on staff for catheter management. Observations revealed that a Certified Nurse Aide (CNA) did not use a gown while performing catheter care, and the drainage port tip was allowed to touch urine in the container, which is against infection control protocols. Additionally, the facility did not provide alcohol wipes for cleaning the drainage port, and the catheter tubing was observed resting on the floor multiple times, increasing the risk of contamination. The facility's care plan and physician orders directed specific catheter care procedures, including monthly catheter changes, catheter care every shift, and the use of Enhanced Barrier Precautions (EBP). However, the facility did not implement EBP due to a lack of understanding, as confirmed by administrative staff. The facility's policy required the catheter and drainage bag to be maintained as a closed system, with the drainage bag kept lower than the bladder and emptied regularly. The failure to adhere to these protocols placed the resident at risk for catheter-related complications and urinary tract infections.
Failure to Implement Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to complete trauma-informed care assessments and develop trauma-informed care plans for two residents diagnosed with PTSD, depression, and anxiety. Resident 52's electronic medical record documented these diagnoses, but there was no evidence of a trauma-informed care assessment. The care plan for Resident 52 lacked interventions related to PTSD, such as identifying triggers and preventing re-traumatization. Observations and interviews with staff revealed a lack of awareness regarding the resident's PTSD and the necessary assessments. Similarly, Resident 71's electronic medical record documented diagnoses of PTSD, depression, anxiety, auditory hallucinations, and schizophrenia. However, there was no evidence of a trauma-informed care assessment after admission. The care plan for Resident 71 also lacked interventions related to PTSD. Staff interviews indicated a lack of awareness about the resident's PTSD and the required assessments. The facility's Trauma Informed Care policy emphasized the importance of implementing trauma-informed approaches to care. Despite this policy, the facility did not complete the necessary assessments and care plans for the residents with PTSD, placing them at risk for unmet behavioral and mental health needs.
Lack of Coordination in Hospice Care for Two Residents
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice providers for two residents, R39 and R31, who were receiving hospice services. For R39, the electronic health record indicated severe cognitive impairment and required extensive assistance with activities of daily living. Despite being admitted to hospice care, R39's care plan lacked specific instructions on the services provided by hospice, such as the frequency and type of support visits, supplies, medical equipment, medications covered by hospice, and hospice contact information. This lack of coordination was confirmed by the facility's administrative nurse and nurse consultant. Similarly, R31, who had intact cognition and required substantial assistance with daily activities, was also receiving hospice services. However, R31's care plan did not include detailed instructions on hospice services, similar to the deficiencies found in R39's care plan. The care plan directed staff to work with hospice to ensure comfort and pain management but lacked specifics on hospice-provided services. This deficiency was also verified by the facility's administrative nurse and nurse consultant. The facility's End of Life Palliative Care and Hospice Care policy outlined the need for a comprehensive and timely interdisciplinary assessment and care plan development based on resident and family preferences, values, goals, and needs. However, the facility failed to implement this policy effectively, as evidenced by the lack of coordination and detailed care plans for residents R39 and R31, placing them at risk for inadequate end-of-life care.
Failure to Prevent Falls in Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide a safe environment for a resident, identified as R2, who experienced multiple falls, one of which resulted in a fractured wrist. R2 had a history of chronic respiratory failure, alcoholic cirrhosis of the liver, congestive heart failure, and anxiety, and was receiving hospice services. Despite these conditions, the facility did not implement adequate interventions to prevent falls, as evidenced by the lack of a change of condition assessment and a comprehensive fall care plan. R2's care plan and assessments indicated a high risk for falls due to factors such as weakness, decreased mobility, medication use, and recent admission to hospice. However, the facility's interventions were insufficient and inconsistent. For instance, after a fall on 06/05/24, the intervention was merely to educate the family not to move the resident. Subsequent falls on 06/12/24 and 06/27/24 resulted in interventions like rearranging furniture and re-educating the resident to use the call light, but these measures did not address the root causes of the falls. Observations and interviews revealed that R2 was often confused, hallucinated, and removed her oxygen tubing, which contributed to her falls. Despite being incontinent and requiring assistance with toileting, there was no documented toileting schedule or plan. Staff interviews confirmed that R2 was not on a toileting program, and the facility lacked a root cause analysis for her falls. The facility's policy for documenting accidents and incidents was not adequately followed, as evidenced by the lack of detailed assessments and interventions to prevent further falls.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wichita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wichita Presbyterian Manor | 0.4 mi | ★★★★★ | 0 | 0 |
| Meridian Rehabilitation And Health Care Center | 1.1 mi | ★★★★★ | 27 | 0 |
| Ascension Living Via Christi Village Mclean | 1.2 mi | ★★★★★ | 14 | 0 |
| Sandpiper Healthcare & Rehabilitation Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Via Christi Village Ridge | 3.5 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.