A list of the most recent deficiencies for St John 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? |
|---|---|---|---|---|
| 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 | 2023-03-08 | 2023-05-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-08 | 2023-05-03 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-03-08 | 2023-05-03 | Y |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-08 | 2023-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-08 | 2023-04-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-08 | 2023-04-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-08 | 2023-04-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-08 | 2023-04-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-08 | 2023-04-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-08 | 2023-03-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-08 | 2023-03-10 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-23 | 2022-04-29 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2021-09-22 | 2021-12-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-09-24 | 2021-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-24 | 2021-12-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-24 | 2021-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-22 | 2021-12-01 | 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 | 2021-09-24 | 2021-11-26 | 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 | 2021-09-24 | 2021-11-26 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-09-24 | 2021-11-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-22 | 2021-11-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-22 | 2021-11-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-09-24 | 2021-11-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-22 | 2021-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-22 | 2021-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-24 | 2021-10-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-24 | 2021-10-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-22 | 2021-10-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-22 | 2021-10-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-09-22 | 2021-10-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-22 | 2021-10-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-30 | 2021-05-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-08 | 2019-10-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-08-08 | 2019-10-07 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-08-08 | 2019-10-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-08 | 2019-10-07 | 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 | 2019-08-08 | 2019-10-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-08-08 | 2019-10-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-08-08 | 2019-10-07 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-08-08 | 2019-10-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-07 | 2019-09-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-07 | 2019-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-07 | 2019-08-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-07 | 2019-08-07 | N |
