Deficiency Records for St Johns Lutheran Home
Updated as of March 01, 2022
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? |
|---|---|---|---|---|
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-01-28 | 2021-02-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-11-23 | 2020-11-23 | 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 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-07-31 | 2020-09-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-07-31 | 2020-09-09 | Y |
| 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 |
| 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 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-10-29 | 2020-01-31 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | 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 |
| 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 |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-10-29 | 2019-12-31 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-29 | 2019-12-31 | Y |
| 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 | Y |
| 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 | Y |
| 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 | Y |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
