Deficiency Records for St Johns Lutheran Home
Updated as of September 01, 2019
This is not the most recent data for St Johns Lutheran Home. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-14 | 2019-03-26 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-02-14 | 2019-03-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-14 | 2019-03-26 | 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 | 2019-02-14 | 2019-03-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-02-14 | 2019-03-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-14 | 2019-03-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-14 | 2019-03-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-14 | 2019-03-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-14 | 2019-03-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-14 | 2019-03-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-14 | 2019-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-14 | 2019-03-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-14 | 2019-03-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-02-14 | 2019-03-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-14 | 2019-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-14 | 2019-03-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-02-14 | 2019-03-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-14 | 2019-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-14 | 2019-03-04 | 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 | 2019-02-14 | 2019-03-04 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-02-14 | 2019-02-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-14 | 2019-02-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-07 | 2019-01-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-21 | 2018-11-22 | Y |
| 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 | 2018-11-21 | 2018-11-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-21 | 2018-06-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-21 | 2018-06-15 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-11-02 | 2017-12-12 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-11-03 | 2017-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-11-02 | 2017-12-01 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-11-03 | 2017-11-29 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-11-03 | 2017-11-29 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-11-03 | 2017-11-29 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-11-03 | 2017-11-29 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-11-03 | 2017-11-29 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-11-03 | 2017-11-29 | N |
| Give or get x-rays and other tests in a timely manner to meet the needs of residents. | Health | 2017-11-03 | 2017-11-29 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-11-03 | 2017-11-27 | N |
| A separate and independent backup electrical power source. | Fire Safety | 2016-10-10 | 2016-12-10 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-10-06 | 2016-11-15 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-10-10 | 2016-10-31 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2016-10-10 | 2016-10-10 | N |
