A list of the most recent deficiencies for Lutheran Retirement 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-22 | 2021-12-21 | 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 | 2021-10-22 | 2021-12-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-22 | 2021-12-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-18 | 2019-05-17 | 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 | 2019-03-18 | 2019-05-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-18 | 2019-05-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-18 | 2019-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-18 | 2019-05-17 | 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 | 2017-09-29 | 2017-11-28 | N |
| Provide hallway or ground-level exits in all residents' rooms. | Fire Safety | 2017-09-29 | 2017-11-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-09-29 | 2017-11-28 | 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 | 2017-09-29 | 2017-11-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-09-29 | 2017-11-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-09-29 | 2017-11-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-09-29 | 2017-11-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-09-29 | 2017-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-09-29 | 2017-11-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-09-29 | 2017-11-28 | N |
