Deficiency Records for Lutheran Home
Updated as of January 01, 2022
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? |
|---|---|---|---|---|
| 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 |
| Post nurse staffing information every day. | Health | 2019-02-25 | 2019-03-15 | Y |
| 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 other general requirements that are deficient. | 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 |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-28 | 2017-11-06 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-09-28 | 2017-11-06 | N |
