Deficiency Records for St Luke Lutheran Community-Portage Lakes
Updated as of March 01, 2024
A list of the most recent deficiencies for St Luke Lutheran Community-Portage Lakes. 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 each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-25 | 2023-11-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-25 | 2023-11-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | 2023-11-16 | 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 | 2023-10-25 | 2023-11-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-25 | 2023-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-25 | 2023-11-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-23 | 2023-06-09 | Y |
| 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 | 2022-06-27 | 2022-07-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-27 | 2022-07-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-27 | 2022-07-13 | 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 | 2022-06-27 | 2022-07-13 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-22 | 2022-07-13 | 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 | 2022-06-22 | 2022-07-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-22 | 2022-07-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-22 | 2022-07-13 | 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 | 2019-08-01 | 2019-09-16 | 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 | 2019-08-01 | 2019-09-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-01 | 2019-09-16 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-07-30 | 2019-09-16 | N |
| Use approved construction type or materials. | Fire Safety | 2019-07-30 | 2019-09-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-30 | 2019-09-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-30 | 2019-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-30 | 2019-09-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-30 | 2019-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-07-30 | 2019-09-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-30 | 2019-09-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-30 | 2019-09-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-30 | 2019-09-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-07-03 | 2018-08-20 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-07-03 | 2018-08-20 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2018-07-03 | 2018-08-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-03 | 2018-08-20 | 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 | 2018-07-03 | 2018-08-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-07-03 | 2018-08-20 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2018-07-03 | 2018-08-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-03 | 2018-08-20 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-07-05 | 2018-08-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-05 | 2018-08-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-07-05 | 2018-08-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-07-05 | 2018-08-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-07-05 | 2018-08-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-05 | 2018-08-20 | N |
