Deficiency Records for Lutheran Living Senior Campus
Updated as of May 01, 2020
This is not the most recent data for Lutheran Living Senior Campus. For the most recent information, click here.
A list of the most recent deficiencies for Lutheran Living Senior Campus. 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? |
|---|---|---|---|---|
| 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 | 2019-10-31 | 2019-11-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-01 | 2019-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-01 | 2019-08-29 | Y |
| 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 | 2019-08-01 | 2019-08-29 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-01 | 2019-08-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-01 | 2019-08-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-01 | 2019-08-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-01 | 2019-08-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-01 | 2019-08-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-01 | 2019-08-29 | Y |
| 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 ne | Health | 2019-08-01 | 2019-08-29 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-08-05 | 2019-08-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-05 | 2019-08-08 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2018-08-09 | 2018-09-05 | Y |
| 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 ne | Health | 2018-08-09 | 2018-09-05 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2018-08-09 | 2018-09-05 | Y |
| 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 | 2018-04-26 | 2018-06-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-26 | 2018-06-01 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-05-02 | 2018-05-10 | 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 | 2018-05-02 | 2018-05-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-05-02 | 2018-05-09 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-02-16 | 2017-03-15 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-02-16 | 2017-03-15 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-02-16 | 2017-03-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-02-16 | 2017-03-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2017-02-16 | 2017-03-15 | N |
| Use approved construction type or materials. | Fire Safety | 2017-02-22 | 2017-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-02-22 | 2017-02-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-02-22 | 2017-02-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-02-22 | 2017-02-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-02-22 | 2017-02-23 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-21 | Not Fixed | Y |
