A list of the most recent deficiencies for Lutheran Retirement 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2023-12-04 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-14 | 2023-01-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-14 | 2023-01-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-14 | 2023-01-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-08 | 2023-01-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-14 | 2022-12-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-14 | 2022-12-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-14 | 2022-12-22 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2022-12-14 | 2022-12-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-20 | 2021-05-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-20 | 2021-05-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-20 | 2021-04-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-20 | 2021-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-20 | 2021-04-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-20 | 2021-04-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-20 | 2021-04-23 | 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 | 2019-06-20 | 2019-07-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-06-21 | 2019-07-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-21 | 2019-07-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-21 | 2019-07-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-21 | 2019-07-21 | N |
