A list of the most recent deficiencies for St John's 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-08 | 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 | 2023-08-08 | 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 | 2023-08-08 | 2023-09-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-08-08 | 2023-09-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-08 | 2023-09-21 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-08-08 | 2023-09-21 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-08-08 | 2023-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-08 | 2023-09-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-08 | 2023-09-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-08 | 2023-09-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-08 | 2023-09-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-08 | 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 | 2023-08-08 | 2023-09-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-08 | 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 |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Establish methods for sharing information. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-07-27 | 2022-09-09 | 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 | 2022-07-27 | 2022-09-09 | 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 | 2022-07-27 | 2022-09-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-07-27 | 2022-09-09 | 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 | 2022-07-27 | 2022-09-09 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-07-27 | 2022-09-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-21 | 2022-08-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-21 | 2022-08-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-21 | 2022-08-26 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-21 | 2022-08-26 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-21 | 2022-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-21 | 2022-08-19 | 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 | 2021-06-30 | 2021-08-14 | 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 | 2021-06-30 | 2021-08-14 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-06-30 | 2021-08-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-30 | 2021-08-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-30 | 2021-08-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-30 | 2021-08-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-30 | 2021-08-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-30 | 2021-08-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-06-30 | 2021-08-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-30 | 2021-08-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-30 | 2021-08-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-30 | 2021-08-14 | 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 | 2021-06-24 | 2021-08-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-24 | 2021-08-06 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-06-24 | 2021-08-06 | N |
