Deficiency Records for Lutheran Retirement Home
Updated as of February 01, 2021
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 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 |
| 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 necessary and PRN use is limited. | 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 |
