A list of the most recent deficiencies for Saint Luke 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-30 | 2023-03-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-30 | 2023-03-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-30 | 2023-03-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-30 | 2023-03-07 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-01-30 | 2023-03-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-30 | 2023-03-07 | Y |
| 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 | 2023-01-26 | 2023-03-07 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-01-26 | 2023-03-07 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-01-26 | 2023-03-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-26 | 2023-03-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-26 | 2023-03-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-26 | 2023-03-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-26 | 2023-03-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-12 | 2022-04-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-08 | 2021-06-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-03 | 2021-04-13 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-02-06 | 2020-03-09 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-02-06 | 2020-03-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-02-06 | 2020-03-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-06 | 2020-03-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-06 | 2020-03-09 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-02-06 | 2020-03-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-02-06 | 2020-03-09 | 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 | 2020-02-06 | 2020-03-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-02-06 | 2020-03-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-02-06 | 2020-03-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-06 | 2020-03-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-04 | 2020-03-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-04 | 2020-03-09 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-02-04 | 2020-03-09 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2020-02-04 | 2020-03-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-04 | 2020-03-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-04 | 2020-03-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-02-04 | 2020-03-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-16 | 2019-02-19 | N |
| Respond appropriately to all alleged violations. | Health | 2019-01-16 | 2019-02-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-16 | 2019-02-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-16 | 2019-02-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-16 | 2019-02-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-16 | 2019-02-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-01-16 | 2019-02-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-01-16 | 2019-02-19 | 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 | 2019-01-16 | 2019-02-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-16 | 2019-02-19 | N |
| Provide or obtain dental services for each resident. | Health | 2019-01-16 | 2019-02-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-16 | 2019-02-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-16 | 2019-02-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-16 | 2019-02-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-01-16 | 2019-02-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-01-16 | 2019-02-19 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2019-01-16 | 2019-02-19 | N |
| Use approved construction type or materials. | Fire Safety | 2019-01-16 | 2019-02-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-16 | 2019-02-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-16 | 2019-02-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-01-16 | 2019-02-19 | N |
