A list of the most recent deficiencies for Lutheran Community 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? |
|---|---|---|---|---|
| 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 | 2023-07-25 | 2023-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-25 | 2023-08-23 | 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 | 2023-07-25 | 2023-08-23 | 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 | 2023-07-25 | 2023-08-23 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-07-25 | 2023-08-23 | N |
| Meet other general requirements. | Fire Safety | 2023-08-07 | 2023-08-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-07 | 2023-08-18 | 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 | 2023-08-07 | 2023-08-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-07 | 2023-08-18 | 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 | 2023-03-21 | 2023-04-17 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-25 | 2022-09-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-25 | 2022-08-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-25 | 2022-08-31 | 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 | 2022-07-25 | 2022-08-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-25 | 2022-08-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-25 | 2022-08-31 | 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 | 2022-07-25 | 2022-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-25 | 2022-08-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-05 | 2022-05-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-07 | 2021-10-01 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Meet other general requirements. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-06-30 | 2021-07-29 | 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 | 2021-06-30 | 2021-07-29 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-30 | 2021-07-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-14 | 2021-07-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-14 | 2021-07-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-14 | 2021-07-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-14 | 2021-07-14 | 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 | 2021-06-14 | 2021-07-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-14 | 2021-07-14 | 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 | 2021-06-14 | 2021-07-14 | 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 | 2021-06-14 | 2021-07-14 | 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 | 2021-06-14 | 2021-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-14 | 2021-07-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-14 | 2021-07-14 | Y |
