A list of the most recent deficiencies for The Lutheran 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? |
|---|---|---|---|---|
| Have exits that are accessible at all times. | Fire Safety | 2023-11-07 | 2024-01-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-11-07 | 2023-11-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-07 | 2023-11-09 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-11-07 | 2023-11-07 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-11-07 | 2023-11-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-07 | 2023-11-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-26 | 2023-02-23 | 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 | 2023-01-26 | 2023-02-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-26 | 2023-02-23 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-01-26 | 2023-02-23 | 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 | 2023-01-26 | 2023-02-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-26 | 2023-02-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-30 | 2023-02-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-30 | 2023-02-13 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-01-30 | 2023-02-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-02-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-30 | 2023-02-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-30 | 2023-02-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-16 | 2022-12-09 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-11-16 | 2022-12-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-23 | 2022-03-04 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-12-10 | 2021-12-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-10 | 2021-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-10 | 2021-12-23 | 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 | 2021-12-10 | 2021-12-23 | 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 | 2021-12-10 | 2021-12-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-12-10 | 2021-12-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-12-10 | 2021-12-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-12-10 | 2021-12-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-12-10 | 2021-12-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-10 | 2021-12-23 | N |
