Deficiency Records for Faith Lutheran Home
Updated as of May 01, 2024
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Deficiency Records for Faith Lutheran Home
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.
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 |
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