Deficiency Records for Lutheran Home
Updated as of March 01, 2019
This is not the most recent data for Lutheran Home. For the most recent information, click here.
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? |
---|---|---|---|---|
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 | 2019-01-13 | N |
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2018-11-27 | 2019-01-13 | 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 | 2019-01-13 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-27 | 2019-01-13 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-27 | 2019-01-13 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-27 | 2019-01-13 | 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 | 2019-01-13 | N |
Be properly staffed | Fire Safety | 2018-11-27 | 2019-01-13 | N |
Have restrictions on the use of portable space heaters. | Fire Safety | 2018-11-27 | 2019-01-13 | N |
Meet other general requirements that are deficient. | Fire Safety | 2018-11-27 | 2019-01-13 | 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 | 2019-01-13 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-27 | 2019-01-13 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-29 | 2019-01-10 | N |
Respond appropriately to all alleged violations. | Health | 2018-11-29 | 2019-01-10 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-29 | 2019-01-10 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-29 | 2019-01-10 | 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 | 2019-01-10 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-11-29 | 2019-01-10 | N |
Provide and implement an infection prevention and control program. | Health | 2018-11-29 | 2019-01-10 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-22 | 2018-06-13 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-12-08 | 2018-01-19 | Y |
Honor each resident's preferences, choices, values and beliefs. | Health | 2017-12-08 | 2018-01-19 | Y |
Install proper backup exit lighting. | Fire Safety | 2017-09-28 | 2017-11-06 | N |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-28 | 2017-11-06 | N |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility | Health | 2017-02-28 | 2017-03-01 | Y |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-01-25 | 2017-02-08 | Y |
Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2016-11-17 | 2016-12-09 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2016-11-17 | 2016-12-09 | N |
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-11-19 | 2016-12-09 | N |
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-11-19 | 2016-12-09 | N |
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2016-11-19 | 2016-12-09 | N |