A list of the most recent deficiencies for 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? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-24 | 2023-10-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-24 | 2023-10-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-24 | 2023-10-12 | 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 | 2023-08-24 | 2023-10-12 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-08-24 | 2023-10-12 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-08-24 | 2023-10-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-08-23 | 2023-10-12 | 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 | 2023-08-23 | 2023-10-12 | 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 | 2023-08-23 | 2023-10-12 | 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 | 2023-08-23 | 2023-10-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-23 | 2023-10-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-23 | 2023-10-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-23 | 2023-10-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-23 | 2023-10-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-23 | 2023-10-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-08-23 | 2023-10-12 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-23 | 2023-10-12 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-08-23 | 2023-10-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-23 | 2023-10-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-23 | 2023-10-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-17 | 2022-09-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-17 | 2022-09-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-31 | 2022-02-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-31 | 2022-02-24 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-31 | 2022-02-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-31 | 2022-02-24 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-01-31 | 2022-02-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-12 | 2021-11-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-01-16 | 2020-02-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-14 | 2020-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-14 | 2020-02-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-14 | 2020-02-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-29 | 2019-01-30 | N |
| Respond appropriately to all alleged violations. | Health | 2018-11-29 | 2019-01-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-29 | 2019-01-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-29 | 2019-01-30 | 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 | 2018-11-29 | 2019-01-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-29 | 2019-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-29 | 2019-01-30 | 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 | 2018-11-27 | 2019-01-30 | N |
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2018-11-27 | 2019-01-30 | 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 | 2018-11-27 | 2019-01-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-27 | 2019-01-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-27 | 2019-01-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-27 | 2019-01-30 | N |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2018-11-27 | 2019-01-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-11-27 | 2019-01-30 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-11-27 | 2019-01-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-11-27 | 2019-01-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-11-27 | 2019-01-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-27 | 2019-01-30 | N |
