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 a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-18 | 2024-01-12 | Y |
| 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 | 2023-12-18 | 2024-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-18 | 2024-01-12 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-06-30 | 2022-08-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-06-30 | 2022-08-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-30 | 2022-08-01 | N |
| Respond appropriately to all alleged violations. | Health | 2022-06-30 | 2022-08-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-06-30 | 2022-08-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-30 | 2022-08-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-30 | 2022-08-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-30 | 2022-08-01 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-06-30 | 2022-08-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-30 | 2022-08-01 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-06-30 | 2022-08-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-30 | 2022-08-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-27 | 2022-08-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-27 | 2022-08-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-27 | 2022-08-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-17 | 2021-10-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-17 | 2021-10-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-20 | 2021-08-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-20 | 2021-08-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-20 | 2021-08-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-20 | 2021-08-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-07-25 | 2019-09-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-07-25 | 2019-09-13 | N |
| Respond appropriately to all alleged violations. | Health | 2019-07-25 | 2019-09-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-25 | 2019-09-13 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-07-25 | 2019-09-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-07-25 | 2019-09-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-25 | 2019-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-25 | 2019-09-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-25 | 2019-09-13 | 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 | 2019-07-25 | 2019-09-13 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-07-25 | 2019-09-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-07-25 | 2019-09-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-25 | 2019-09-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-25 | 2019-09-13 | 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 | 2019-07-25 | 2019-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-25 | 2019-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-25 | 2019-09-13 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2019-07-23 | 2019-09-13 | 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 | 2019-07-23 | 2019-09-13 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-07-23 | 2019-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-23 | 2019-09-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-23 | 2019-09-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-23 | 2019-09-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-23 | 2019-09-13 | 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 | 2019-07-25 | 2019-09-05 | 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 | 2018-06-20 | 2018-07-26 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-06-20 | 2018-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-20 | 2018-07-26 | N |
