Deficiency Records for Lutheran Retirement Home
Updated as of March 01, 2020
This is not the most recent data for Lutheran Retirement Home. For the most recent information, click here.
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? |
---|---|---|---|---|
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 | 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 |
Establish policies and procedures for volunteers. | Fire Safety | 2018-03-21 | 2018-04-21 | N |
Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2018-03-21 | 2018-04-21 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-21 | 2018-04-21 | N |
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-03-21 | 2018-04-21 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2018-03-21 | 2018-04-21 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2018-03-21 | 2018-04-21 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-03-21 | 2018-04-21 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-21 | 2018-04-21 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-03-19 | 2018-04-15 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-03-19 | 2018-04-15 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-03-19 | 2018-04-15 | N |
Respond appropriately to all alleged violations. | Health | 2018-03-19 | 2018-04-15 | N |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-03-19 | 2018-04-15 | 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 ne | Health | 2018-03-19 | 2018-04-15 | N |
Provide properly protected cooking facilities. | Fire Safety | 2017-01-26 | 2017-02-26 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-01-26 | 2017-02-26 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-01-26 | 2017-02-26 | N |
Use approved construction type or materials. | Fire Safety | 2017-01-26 | 2017-02-02 | N |