A list of the most recent deficiencies for Faith 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-18 | 2023-02-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-18 | 2023-02-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-18 | 2023-02-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-18 | 2023-02-18 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-01-18 | 2023-02-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-12 | 2023-02-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-01-12 | 2023-02-12 | 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 | 2023-01-12 | 2023-02-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-18 | 2023-01-18 | 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 | 2021-06-17 | 2021-07-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-17 | 2021-07-08 | 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 | 2021-06-17 | 2021-07-08 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-06-17 | 2021-07-08 | 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 | 2021-06-17 | 2021-07-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-17 | 2021-07-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-17 | 2021-07-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-06-17 | 2021-07-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-10 | 2021-06-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-06-10 | 2021-06-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-10 | 2021-06-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-06-10 | 2021-06-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-06-10 | 2021-06-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-10 | 2021-06-16 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-10 | 2021-06-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-10 | 2021-06-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-10 | 2021-06-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-17 | 2019-07-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-17 | 2019-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-17 | 2019-07-26 | 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 | 2019-07-17 | 2019-07-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-11 | 2019-07-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-07-11 | 2019-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-11 | 2019-07-24 | 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 | 2019-07-11 | 2019-07-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-07-17 | 2019-07-19 | 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 | 2019-07-17 | 2019-07-17 | N |
