A list of the most recent deficiencies for Lutheran Nursing 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 basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-09-28 | 2023-11-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | 2023-11-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-28 | 2023-11-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-11-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-28 | 2023-11-14 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-09-28 | 2023-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-28 | 2023-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-28 | 2023-11-14 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2023-09-28 | 2023-11-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-28 | 2023-11-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-09-28 | 2023-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-28 | 2023-11-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-13 | 2022-05-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-13 | 2022-05-28 | 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 | 2022-04-13 | 2022-05-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-13 | 2022-05-28 | 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 | 2022-04-13 | 2022-05-28 | N |
| Provide or obtain dental services for each resident. | Health | 2022-04-13 | 2022-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-13 | 2022-05-28 | N |
| Report COVID19 data to residents and families. | Health | 2022-04-13 | 2022-05-28 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-13 | 2022-05-28 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-13 | 2022-05-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-13 | 2022-05-28 | 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 | 2019-06-14 | 2019-07-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-06-14 | 2019-07-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-14 | 2019-07-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-14 | 2019-07-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-14 | 2019-07-29 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2019-06-14 | 2019-07-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-14 | 2019-07-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-14 | 2019-07-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-14 | 2019-07-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-14 | 2019-07-29 | 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 | 2019-06-14 | 2019-07-29 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-06-14 | 2019-07-29 | N |
| Dispose of garbage and refuse properly. | Health | 2019-06-14 | 2019-07-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-06-14 | 2019-07-29 | N |
