A list of the most recent deficiencies for Lutheran Home For The Aged. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-24 | 2024-02-12 | Y |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2024-01-16 | 2024-02-07 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| 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. | Health | 2023-12-20 | 2024-01-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-12-20 | 2024-01-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-20 | 2024-01-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-20 | 2024-01-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-20 | 2024-01-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-20 | 2024-01-13 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-12-20 | 2024-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-20 | 2024-01-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-06 | 2023-12-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-06 | 2023-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-10 | 2023-10-25 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-06-21 | 2023-06-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-24 | 2023-06-22 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-24 | 2023-06-22 | Y |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-23 | 2023-03-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-01 | 2023-02-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-01 | 2023-02-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-01 | 2023-02-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-25 | 2023-02-22 | N |
| 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. | Health | 2023-01-25 | 2023-02-22 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-01-25 | 2023-02-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-25 | 2023-02-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-25 | 2023-02-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-25 | 2023-02-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-25 | 2023-02-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-25 | 2023-02-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-25 | 2023-02-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-25 | 2023-02-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-01-25 | 2023-02-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-01-25 | 2023-02-22 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-01-25 | 2023-02-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-01-25 | 2023-02-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-25 | 2023-02-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2022-11-30 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-10-24 | 2022-11-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-28 | 2022-08-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-13 | 2022-08-03 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-04-20 | 2022-05-03 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-04-20 | 2022-05-03 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-04-20 | 2022-05-03 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-04-20 | 2022-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-20 | 2022-05-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-20 | 2022-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-20 | 2022-05-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-20 | 2022-05-03 | N |
| 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. | Health | 2022-04-07 | 2022-04-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-07 | 2022-04-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-07 | 2022-04-28 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-04-07 | 2022-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-07 | 2022-04-28 | N |
| Provide activities to meet all resident's needs. | Health | 2022-03-21 | 2022-04-04 | Y |
