A list of the most recent deficiencies for Lutheran Care Center. 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? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-23 | 2023-08-17 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-06-23 | 2023-07-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-06-23 | 2023-07-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-09 | 2023-07-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-09 | 2023-07-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-06-09 | 2023-07-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-06-23 | 2023-07-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-23 | 2023-07-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-23 | 2023-06-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-23 | 2023-06-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-17 | 2022-07-29 | 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 | 2022-06-17 | 2022-07-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-17 | 2022-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-01 | 2022-07-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-07-01 | 2022-07-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-07-01 | 2022-07-29 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-07-01 | 2022-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-21 | 2021-06-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-21 | 2021-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-21 | 2021-06-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-23 | 2021-05-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-23 | 2021-05-06 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-04-23 | 2021-05-06 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-23 | 2021-05-06 | 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 | 2021-04-23 | 2021-05-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-23 | 2021-05-06 | 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 | 2021-04-23 | 2021-05-06 | 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 | 2021-04-23 | 2021-05-06 | N |
