A list of the most recent deficiencies for St Johns 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? |
|---|---|---|---|---|
| Have exits that are accessible at all times. | Fire Safety | 2022-09-28 | 2023-06-16 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-28 | 2022-11-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-09-28 | 2022-11-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-28 | 2022-11-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-28 | 2022-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-28 | 2022-11-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-28 | 2022-11-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-09-28 | 2022-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-28 | 2022-11-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-28 | 2022-11-18 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-28 | 2022-11-18 | 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 | 2022-09-29 | 2022-11-14 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-09-29 | 2022-11-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-09-29 | 2022-11-10 | 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 | 2022-09-29 | 2022-11-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-09-29 | 2022-11-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-29 | 2022-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-29 | 2022-11-10 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-09-29 | 2022-11-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-28 | 2022-11-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-28 | 2022-10-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-17 | 2021-12-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-09-18 | 2020-10-23 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-09-18 | 2020-10-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-09-18 | 2020-10-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-09-18 | 2020-10-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-09-18 | 2020-10-23 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2020-09-18 | 2020-10-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-18 | 2020-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-18 | 2020-10-23 | N |
| Install proper backup exit lighting. | Fire Safety | 2020-09-16 | 2020-10-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-09-16 | 2020-10-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-09-16 | 2020-10-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-09-16 | 2020-09-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-09-16 | 2020-09-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-09-16 | 2020-09-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-09-16 | 2020-09-26 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-09-16 | 2020-09-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-09-16 | 2020-09-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-29 | 2020-01-31 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-29 | 2020-01-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-29 | 2020-01-31 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-10-29 | 2019-12-31 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-10-29 | 2019-12-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-29 | 2019-12-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-29 | 2019-12-31 | 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 | 2019-10-29 | 2019-12-31 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-10-29 | 2019-12-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-29 | 2019-12-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-29 | 2019-12-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-29 | 2019-12-31 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-29 | 2019-12-31 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-29 | 2019-12-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-29 | 2019-12-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-10-29 | 2019-12-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-10-29 | 2019-12-31 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-29 | 2019-12-31 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-10-29 | 2019-12-31 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-10-29 | 2019-12-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-29 | 2019-12-31 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-10-29 | 2019-12-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-10-29 | 2019-12-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-29 | 2019-12-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-23 | 2019-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-23 | 2019-12-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-23 | 2019-12-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-23 | 2019-12-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-23 | 2019-12-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-23 | 2019-12-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-23 | 2019-12-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-23 | 2019-12-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-29 | 2019-10-02 | N |
