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Deficiency Records for Northgate Unit of Lakeview Christian Home
A list of the most recent deficiencies for Northgate Unit of Lakeview Christian Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Northgate Unit of Lakeview Christian Home. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-29 | 2024-05-29 | 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 | 2024-03-29 | 2024-05-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-29 | 2024-05-29 | 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 | 2024-03-29 | 2024-05-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-03-29 | 2024-05-29 | 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 | 2024-03-29 | 2024-05-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-29 | 2024-05-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-29 | 2024-05-29 | 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 | 2024-03-29 | 2024-05-29 | 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 | 2024-03-29 | 2024-05-29 | 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 | 2024-03-29 | 2024-05-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-29 | 2024-05-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-29 | 2024-05-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-03-29 | 2024-05-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-03-29 | 2024-05-29 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-03-29 | 2024-05-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-03-27 | 2024-05-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-27 | 2024-05-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-27 | 2024-05-29 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-03-27 | 2024-05-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-27 | 2024-05-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-27 | 2024-05-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-05 | 2023-06-09 | 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 | 2023-04-07 | 2023-05-07 | 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 | 2023-04-07 | 2023-05-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-04-07 | 2023-05-07 | 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 | 2023-04-07 | 2023-05-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-07 | 2023-05-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-07 | 2023-05-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-07 | 2023-05-07 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-04-05 | 2023-05-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-05 | 2023-05-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-05 | 2023-05-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-05 | 2023-05-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-05 | 2023-05-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-05 | 2023-05-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-05 | 2023-05-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-04 | 2022-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-04 | 2022-03-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-09 | 2022-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-09 | 2022-03-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-09 | 2022-03-31 | N |
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