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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-22 | 2024-03-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-22 | 2024-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-22 | 2024-03-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-02-22 | 2024-03-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-22 | 2024-03-06 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-02-22 | 2024-03-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-02-22 | 2024-03-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-02-22 | 2024-03-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-22 | 2024-03-04 | 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 | 2024-02-15 | 2024-02-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-15 | 2024-02-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-15 | 2024-02-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-02-15 | 2024-02-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-15 | 2024-02-28 | 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 | 2024-02-15 | 2024-02-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-15 | 2024-02-28 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-22 | 2024-02-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-22 | 2024-02-26 | 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 | 2024-02-22 | 2024-02-23 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-02-22 | 2024-02-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-22 | 2024-02-23 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2024-02-22 | 2024-02-23 | N |
| 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 |
