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Deficiency Records for St John's Lutheran Home
View the most recent health deficiencies and inspection results for St John's Lutheran Home. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for St John's Lutheran Home. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-07-17 | 2025-09-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2025-07-17 | 2025-09-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2025-07-17 | 2025-09-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-07-17 | 2025-09-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-07-17 | 2025-09-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-07-17 | 2025-09-04 | N |
| Ensure gas cylinders are properly stored. | Fire Safety | 2025-07-17 | 2025-09-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-07-17 | 2025-09-04 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-07-17 | 2025-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-07-17 | 2025-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-07-17 | 2025-08-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2025-07-17 | 2025-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-07-17 | 2025-08-30 | 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 | 2025-07-17 | 2025-08-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-07-17 | 2025-08-30 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-15 | 2024-10-03 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-08-15 | 2024-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-15 | 2024-10-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-08-15 | 2024-10-03 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-08-15 | 2024-09-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-15 | 2024-09-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-15 | 2024-09-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-08-15 | 2024-09-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-08-15 | 2024-09-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-15 | 2024-09-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-08-15 | 2024-09-16 | N |
| Post nurse staffing information every day. | Health | 2024-08-15 | 2024-09-16 | 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 | 2024-08-15 | 2024-09-16 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-08-15 | 2024-09-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-08-15 | 2024-09-16 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-08-15 | 2024-09-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-08-15 | 2024-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-15 | 2024-09-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-15 | 2024-09-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-15 | 2024-09-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-15 | 2024-09-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-15 | 2024-09-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-23 | 2024-04-19 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-03 | 2023-09-21 | 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 | 2023-08-03 | 2023-09-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-03 | 2023-09-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-03 | 2023-09-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-03 | 2023-09-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-03 | 2023-09-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-03 | 2023-09-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-03 | 2023-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-03 | 2023-09-15 | 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 | 2023-08-03 | 2023-09-15 | Y |