Northgate Unit Of Lakeview Christian Home

Based on observation and interview, the facility failed to ensure call lights in residents' rooms were within resident's reach for 1 (R #2) of 4 (R #2, R #7, R #12, R #20) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they need assistance. The findings are: A. On 05/17/26 at 12:51 pm, during an interview and observation with R #2 in his room, R #2 was attempting to activate his call light and could not get it activated. R #2 stated that he likes the tap activated call light because it is easier for him to use.B. On 05/17/26 at 12:55 pm, during an interview with Certified Nurse Aide (CNA) #4, she could not activate the call light until she raised the position of R #2's bed. CNA #4 confirmed that the cord to R #2's call light was pinched between the bed and was stopping the call light from working.

Based on observation and interview, the facility failed to safeguard resident's personal health information by leaving a list of residents with their associated vital sign readings in plain view. This deficient practice had the potential to affect all 38 people residing in the rooms on the East 1 and East 2 halls by allowing unauthorized people access to their personal health information. The findings are: A. On 08/27/25 at 1:00 pm, a random observation of the facility revealed a paper document with names of the residents and their vital sign readings sitting face up on the nurses station countertop. B. On 08/27/25 at 1:11 pm, during an interview with ST #1 confirmed that the clipboard was left face up with resident information visible. C. On 08/27/25 at 3:15 pm, during an interview with the Director of Nursing (DON), she confirmed that all personal health information should be safeguarded and should never be left in view of people that are not authorized to see it.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff)) was accurate for 1 (R #1) of 1 (R #1) resident reviewed for MDS assessment accuracy. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #1's admission Record revealed the following diagnoses: 1. Dizziness (sensation of feeling faint).2. Senile Dementia (a mental deterioration associated with age by loss of intellectual ability). 3. Osteoporosis (bones become extremely porous and are subject to fracture and slow healing). B. Record review of progress notes dated 03/18/25 revealed the resident had an unwitnessed fall at 7:00 pm. C. Record review of R #1's physician orders revealed the following: 1. An order dated 03/18/25, Initiate Fall Prevention Program; Lower bed at appropriate height to prevent fall/injury.2. An order dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to wear hairnets while in the kitchen. This deficient practice is likely to affect all 79 residents listed on the resident census list provided by the Administrator on 04/02/25. The findings are: A. On 04/04/25 at 12:23 pm, a random observation of the kitchen revealed Dietary Aide #1 and Dietary Aide #2 were not wearing a hairnet while in the kitchen. B. On 04/04/25 at 12:46 pm during an interview with Assistant Dietary Manager, she confirmed that all staff should be wearing hairnets while in the kitchen.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 2 (R #33 and R #51) of 4 (R #1, R #3, R #33 and R #51) residents reviewed for care plans. This deficient practice is likely to result in staff being unaware of the current and actual needs of the residents. The findings are: R #33 A. Record review of R #33's Face Sheet revealed she was admitted to the facility on [DATE]. B. Record review of R #33's care plan dated 04/19/24 revealed that R #33 requires oxygen therapy. C. Record review of R #33's current medical orders revealed no order for the use of supplemental oxygen. D. On 04/04/25 at 2:45 pm during an interview with the Director of Nursing (DON) she stated that R #33 does not use supplemental oxygen. The DON confirmed that R #33's care plan is not accurate. R #51 E. Record review of R #51's Face Sheet revealed she was originally admitted to the facility on [DATE] with the following diagnoses: 1. Atherosclerotic (plaque…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 2 (R #34, and R #51) of 4 (R #3, R #33, R #34, and R #51) residents reviewed when staff failed to: 1. Revise #34's care plan for the use of assist bars. 2. Revise #51's care plan for hospice care. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #34 A. Record review of R #34's face sheet revealed R #34 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: 1. Abnormalities of gait and mobility (a deviation from the normal pattern of walking), 2. Lack of coordination, 3. Polyosteoarthritis (a condition where pain and inflammation occur in multiple joints at once), 4. Parkinsons disease (a progressive neurological disorder that primarily affects movement) with Dyskinesia (a movement disorder characterized by involuntary, repetitive, and often purposeless…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #58) of 2 (R #51 and R #58) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the residents not receiving the services they need. The findings are: A. Record review of R #58's Face Sheet revealed R #58 was admitted to the facility on [DATE] with multiple diagnoses including a diagnosis of major depressive disorder (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), recurrent. B. Record review of R #58's PASRR dated 05/31/24, revealed staff documented that R #58 does not have a diagnosis or suspected mental illness. C. On 04/03/25 at 2:31 pm, during an interview with the Director of Nursing (DON), she stated R #58 does have a diagnosis of major depressive disorder which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 18 people residing in the 200 through 216 rooms by allowing unauthorized people access to their medical supplies and personal health information. The findings are: A. On 04/02/25 at 9:38 am, during a random observation of the facility, the treatment cart located in the the hall of the 200 rooms was unlocked, and the facility employees were not in the area. B. On 04/02/25 at 9:42 am, during an interview with Case Manager (CM) #1, he confirmed the treatment cart was unlocked and then walked away from the area. C. On 04/02/25 at 9:43 am, during an interview with Registered Nurse (RN) #1, he confirmed the treatment cart was unlocked and locked the cart. RN #1 stated the treatment cart should be locked and secured while not in use.

Based on observation and interview, the facility failed to serve food under sanitary conditions by professional standards of food service safety. This failure could potentially affect all 76 residents in the facility who eat food prepared in the kitchen. Residents were identified by the Resident Matrix provided by the Administrator on 03/25/24. When they failed to: 1. Have staff perform hand hygiene when distributing food trays to residents in the H Unit. 2. Have staff perform hand hygiene when assisting residents in the main dining room. If the facility fails to adhere to safe food handling practices and hygiene practices, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 03/26/24 at 11:27 AM, during an observation of the dining room of the H Unit revealed the following: 1. CNA #33 did not wash or sanitize her hands with hand sanitizer in between meal pass. B. On 03/26/24 at 11:31 AM, during an observation of the dining room the following was revealed: 1. CNA #24 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This deficient practice has the potential to affect all 76 residents in the facility. Residents identified on the matrix provided by the Administrator on 03/25/24. This deficient practice could likely result in the inappropriate use of antibiotics that can lead to resistance of multi-drug resistant organisms. The findings are: A. Record review of the Antibiotic Sterwardship Program Policy dated 02/29/24, revealed that nursing staff will conduct an antibiotic timeout within 48-72 hours of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. B. On 03/26/24 at 10:49 AM, during an interview with family member (FM) #1, he said R #31 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to provide reasonable accommodation of resident needs for 2 (R #37 and R #41) of 2 (R #37 and R #41) residents reviewed for care when the facility failed to ensure that resident's bedside table with frequently used items were within the resident's reach. This deficient practice could result in the residents' needs not being met, leaving them at risk for accidents and falls. The findings are: R #37 A. On 03/26/24 at 10:10 AM, during an interview and observation of R #37, the following was revealed: 1. R #37 sat in chair next to his bed. 2. R #37's call bell sat on R #37's bed behind him. The call bell was out of R #37's eye sight and out of his reach. 3. R #37's bedside table with drinks was at the foot of R #31's bed and was approximately four feet away from resident 4. R #37 stated that he was unable to get up on his own and unable to get his drinks. B. On 03/26/24 at 10:31 AM, during an interview with CNA #22, she confirmed the following: 1. R #37 was not able to get up on his own. 2. R #37's drinks were out of his reach. 3.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure that residents, their representatives, and the Ombudsman (a resident advocate that is a government employee who investigates and tries to resolve complaints, usually through recommendations or mediation) received a written notice of transfer as soon as practicable for 6 (R #16, R #24, R #34, R #37, R #59, and R #65) of 6 (R #16, R #24, R #34, R #37, R #59, and R #65) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was discharged . The findings are: R #16 A. Record review of R #16's medical record revealed the following: 1. R #16 was transferred to the hospital on [DATE] after a fall. 2. Staff did not provide a written transfer notice to R #16 or her representative. 3. Staff did not provide a copy of a written transfer notice to the Office of the State Ombudsman. R #24 B. Record review of R #24's medical record revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 6 (R #16, R #24, R #34, R #37, R #59, and R #65) of 6 (R #16, R #24, R #34, R #37, R #59, and R #65) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #16 A. Record review of R #16's medical record revealed the following: 1. R #16 was transferred to the hospital on [DATE] after a fall. 2. R #16's medical record did not contain a written notice of bed hold policy for the transfer on 02/18/24. R #24 B. Record review of R #24's medical record revealed the following: 1. R #24 was transferred to the hospital on [DATE] due to having blood in her stool. 2. R #24's medical record did not contain a written notice of bed hold policy for the transfer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure care plan revision and care plan meeting requirements occurred for 10 (R #4, R #12, R #16, R #24, R #31, R #37, R #39, R #59, R #65, and R #179) of 13 (R #4, R #12, R #16, R #24, R #31, R #37, R #39, R #52, R #57, R #58, R #59, R #65, and R #179) residents reviewed for care plans when they failed to: 1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities, and includes other appropriate staff or professionals in disciplines as determined by the resident's needs) members (Hospice and R #39) as well as resident representatives participate in the care plan meeting for R #31 and R #39. 2. Have the care plan meeting within seven days after the completion of the MDS assessment for R #31. 3. Revise the care plan with the most current resident information for R #4, R #16, R #24, R #37, R #39, R #59, R…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (R #59 and R #65) of 2 (R #59 and R #65) residents when they failed to: 1. Start antibiotics for R #59 until five days after the positive urine culture (test result that shows the presence of bacteria in the urine) received. 2. Place compression stockings on R #65's legs as ordered by physician. These deficient practices could likely lead to residents needs not being met and/or a worsening of their condition. The findings are: R #59 A. Record review of R #59's medical record revealed: 1. A urine culture (lab test to detect and identify bacteria in urine that can cause infection) and sensitivity (report that identifies which antibiotics are most effective against the bacteria identified), final report date 09/27/23 revealed R #59's urine culture was positive for Escherichia Coli (E. Coli; bacteria normally found in the gastrointestinal tract that can often cause urinary infection by entering the urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to keep residents free from accidents for all 53 residents in the East Unit and H Unit. Residents were identified by the resident Census provided by the Administrator on 03/25/24, when they failed to: 1. Keep treatment carts (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools.) locked when not supervised by staff. 2. Ensure the fall mat (a safety feature that is placed along the side of the bed to prevent injury) was placed next to R #41's bed. These deficient practices could likely result in injury to residents due to falling without a fall mat or residents obtaining medical equipment which can cause injury/death. The findings are: Treatment Carts A. On 03/25/24 at 1:29 PM, during an observation of the East Unit, the treatment cart was unlocked and staff were not present. B. On 03/25/24 at 1:31 PM, during an interview RN #31 confirmed treatment cart was unlocked. RN #31 confirmed that the treatment carts are supposed to be locked. C. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the the physician provided rationale for not following the pharmacist's recommendation for 2 (R #36 and R #41) of 2 (R #36 and R #41) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions or adverse side effects. The findings are: R #36 A. Record review of the pharmacy consultation report for R #36, dated 02/27/24, revealed: 1. R #36 received Metformin (insulin), 500 mg bid (twice daily), for diabetes. 2. The pharmacist recommended increasing the dosage to 500 mg TID (three times daily). 3. The provider denied the recommendation but did not provide a rationale. B. Record review of R #36's physician's orders revealed that R #36 had an order dated 03/04/23 for Metformin 500 mg, 1 tablet twice a day. C. On 03/29/24 at 11:14 AM, during an interview, the DON confirmed that the provider did not provide a rationale for denying the recommendation. R #41 D. Record review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to: 1. Initiate a gradual dose reduction (GDR; decreasing a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) of medication as recommended by the pharmacist and ordered by the facility provider. 2. Ensure the medical record has documented rationale as to why the facility provider does not want to complete a GDR. for 2 (R #24 and R #41) of 5 (R #15, R #16, R #24, R #36, and R #41) residents reviewed for unnecessary medication. If consultant pharmacist recommendations and physician's orders are not implemented in a timely manner, residents are likely to be administered medications they do not need and could likely suffer from adverse side effects. The findings are: R #24 A. Record review of consultant pharmacist progress note for R #24, dated 12/31/23, revealed: 1. [Name of R #24] received Depakote (medication used to treat seizures, bipolar disorder, and prevent migraines) mg daily (decreased 02/12/23) gabapentin (medication used to prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to store medications properly and ensure medication carts were locked for all 53 residents in the East Unit and in the H Unit/ Residents were identified by the resident census list provided by the Administrator on 03/25/24, when they failed to: 1. Secure a medication cart on the H Unit. 2. Ensure the medication carts did not contain loose medications. 3. Ensure that insulin is stored per manufacturer's instructions. These deficient practices could likely result in residents obtaining or being administered medication not prescribed to them, residents receiving medications that are less effective and may result in adverse side effects. The findings are: Unlocked Medication Carts A. On 03/26/24 at 12:15 PM, during an observation of the H Unit, the medication cart was unlocked and staff was not present. B. On 03/26/24 at 12:20 PM, during an interview with RN #32, he confirmed the medication cart was unlocked. RN #32 stated the medication cart should be locked. C. On 04/02/24 at 12:02 PM, during an interview with the DON, she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow proper infection control practices for 3 (R #14, R #65 and R #179) of 3 (R #14, R #65 and R #179) residents identified during random observation when the facility failed to ensure resident's nasal cannulas (a device that delivers extra oxygen through a tube and into your nose) were labeled with the date that they were changed. This deficient practice could likely result in the spread of contagious and resistant illnesses to other residents. The findings are: R #14 A. On 03/28/24 at 4:02 PM, during an observation of the dinning area, R #14 sat in her wheelchair, wore a nasal cannula attached to the portable oxygen tank on her wheelchair. Staff did not label the nasal cannula with a date that indicated a date the nasal cannula was changed. B. On 03/28/24 at 4:03 PM, during an interview, RN #11 confirmed that staff did not date the tubing. RN #11 also confirmed that there should be a date on it. [Facility practice is to change the nasal cannulas weekly and date the cannulas for tracking purposes.] R #65…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure call lights worked and that the pull cords for the call lights in the resident's bathrooms were in reach to allow residents to call for help using the call light system, for 10 (R #5, R #11, R #21, R #28, R #30, R #36, R #37, R #41, R #54 and R #68) of 10 (R #5, R #11, R #21, R #28, R #30, R #36, R #37, R #41, R #54 and R #68) residents randomly sampled for call light function, when the facility failed the following: 1. To have the pull cords for the call light system in the resident's bathrooms in reach from the floor for R #5, R #11, R #21, R #28, R #30, R #36, R #37, R #41, R #54 and R #68. 2. The alarm sound for the call lights in R #36 and R #68's rooms worked. 3. Ensure the call light were within reach for R #37 and R #41. This deficient practice could likely result in residents being unable to call for assistance and staff not hearing the alarm for the call light. The findings are: R #36 A. On 03/25/24 at 3:45 PM, during an interview, R #36 said that her call light on her bed lights up but that the alarm does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide abuse, neglect, and exploitation (ANE) training and Dementia Management training to 4 (CNA #26, LPN #21, LPN #22, and RN #21) of 6 (CNA #25, CNA #26, CNA #27, LPN #21, LPN #22, and RN #21) staff sampled for training. This deficient practice could likely result in staff not knowing who, what, and when to report abuse, neglect, and exploitation. The findings are: A. Record review of CNA #26's training transcript for date range 03/01/23 through 02/29/2, revealed CNA #26 did not complete the Dementia Management training. B. Record review of LPN #21's training transcript for date range 03/01/23 through 02/29/24, revealed LPN #21 did not complete the Dementia Management training. C. Record review of LPN #22's training transcript for date range 03/01/23 through 02/29/24, revealed LPN #22 did not complete the ANE training. D. Record review of RN #21's training transcript for date range 03/01/23 through 02/29/24, revealed RN #21 did not complete the Dementia Management training. E. On 03/29/24 at 4:28 PM, during an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; assessment instrument completed by facility staff) was accurate for 1 (R #58) of 6 (R #4, R #7, R #24, R #52, R #57, and R #58) residents reviewed for MDS accuracy. This deficient practice could likely result in the facility not having an accurate assessment of resident's care needs. The findings are: A. Record review of R #58's nursing progress note dated 12/16/23 at 11:59 AM, revealed that staff documented that R #58 complained of burning pain upon urination. B. Record review of R #58's McGreer's Criteria form (surveillance tool that is used to help identify and track infections among residents) dated 12/16/23 at 2:05 PM revealed: 1. Acute dysuria (painful urination) or acute pain was marked yes. 2. At least 100,000 colony count (number of bacteria in a urine sample indication urinary infection) of no more than 2 species of microorganisms (microscopic organism, especially a bacteria, virus, or fungus) in a voided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.