Deficiency Records for Lutheran Senior Services at Breeze Park
Updated as of March 01, 2024
A list of the most recent deficiencies for Lutheran Senior Services at Breeze Park. 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? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-17 | 2022-12-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-17 | 2022-07-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-17 | 2022-07-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-17 | 2022-07-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-17 | 2022-07-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-17 | 2022-07-29 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-06-17 | 2022-07-29 | N |
| Use approved construction type or materials. | Fire Safety | 2022-06-17 | 2022-07-29 | 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 | 2022-06-17 | 2022-07-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-17 | 2022-07-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-17 | 2022-07-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-17 | 2022-07-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-17 | 2022-07-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-17 | 2022-07-29 | N |
| Meet other general requirements. | Fire Safety | 2022-06-17 | 2022-07-29 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-11 | 2019-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-11 | 2019-11-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-10-11 | 2019-11-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-10-11 | 2019-11-22 | 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 | 2019-10-11 | 2019-11-22 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-10-11 | 2019-11-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-11 | 2019-11-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-11 | 2019-11-22 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-10-11 | 2019-11-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-10-11 | 2019-11-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-11 | 2019-11-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-10-11 | 2019-10-11 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2018-08-23 | 2019-02-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-23 | 2019-02-22 | 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 | 2018-08-23 | 2018-10-05 | 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 | 2018-08-23 | 2018-10-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-23 | 2018-10-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-08-23 | 2018-10-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-08-23 | 2018-10-05 | N |
| Use approved construction type or materials. | Fire Safety | 2018-08-23 | 2018-10-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-23 | 2018-10-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-23 | 2018-10-05 | N |
