A list of the most recent deficiencies for Lakeside 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? |
|---|---|---|---|---|
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-01-26 | 2023-02-26 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-26 | 2023-02-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-26 | 2023-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-26 | 2023-02-26 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-26 | 2023-02-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-31 | 2023-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-31 | 2023-02-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-31 | 2023-02-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-31 | 2023-01-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-18 | 2022-11-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-18 | 2022-11-18 | Y |
| 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 | 2021-07-29 | 2021-08-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-29 | 2021-08-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-07-29 | 2021-08-27 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-07-29 | 2021-08-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-29 | 2021-08-27 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-08-04 | 2021-08-13 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-08-04 | 2021-08-10 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-08-04 | 2021-08-10 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2021-08-04 | 2021-08-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-06 | 2021-04-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-06 | 2021-04-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-26 | 2019-10-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-09-26 | 2019-10-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-26 | 2019-10-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-26 | 2019-10-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-26 | 2019-10-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-26 | 2019-10-29 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-09-26 | 2019-10-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-26 | 2019-10-29 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-26 | 2019-10-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-26 | 2019-10-29 | 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 | 2019-09-26 | 2019-10-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-26 | 2019-10-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-26 | 2019-10-29 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-09-26 | 2019-10-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-03 | 2019-10-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-03 | 2019-10-16 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-10-03 | 2019-10-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-03 | 2019-10-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-03 | 2019-10-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-03 | 2019-10-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-03 | 2019-10-04 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2019-10-03 | 2019-10-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-03 | 2019-10-03 | N |
