A list of the most recent deficiencies for Lutheran Village at Wolfcreek. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-13 | 2023-05-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-13 | 2023-05-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-13 | 2023-05-29 | N |
| Provide activities to meet all resident's needs. | Health | 2023-04-13 | 2023-05-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-13 | 2023-05-29 | 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 | 2023-04-13 | 2023-05-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-13 | 2023-05-29 | 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 | 2023-04-13 | 2023-05-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-13 | 2023-05-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-13 | 2023-05-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-13 | 2023-05-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-13 | 2023-05-29 | 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 | 2023-04-13 | 2023-05-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-13 | 2023-05-29 | 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 | 2023-04-10 | 2023-05-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-10 | 2023-05-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-10 | 2023-05-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-13 | 2023-05-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-15 | 2023-04-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-15 | 2023-04-03 | Y |
| 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 | 2021-11-23 | 2021-12-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-28 | 2021-12-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-12-12 | 2020-03-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-12-12 | 2020-03-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-12-12 | 2020-03-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-12 | 2020-03-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-12 | 2020-03-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-09 | 2020-03-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-09 | 2020-03-04 | N |
| 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 | 2018-10-18 | 2018-11-26 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-10-18 | 2018-11-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-10-18 | 2018-11-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-18 | 2018-11-26 | 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 | 2018-10-18 | 2018-11-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-18 | 2018-11-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-18 | 2018-11-26 | 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 | 2018-10-18 | 2018-11-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-18 | 2018-11-26 | 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 | 2018-10-18 | 2018-11-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-18 | 2018-11-26 | 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 | 2018-10-18 | 2018-11-26 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-10-18 | 2018-11-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-18 | 2018-11-26 | 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 | 2018-10-18 | 2018-11-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-18 | 2018-11-26 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-10-17 | 2018-11-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-17 | 2018-11-26 | N |
