Deficiency Records for St Luke Lutheran Community-Portage Lakes
Updated as of February 01, 2019
This is not the most recent data for St Luke Lutheran Community-Portage Lakes. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Be properly staffed | 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 |
| 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 ne | 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 |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-03-01 | 2018-04-20 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-03-01 | 2018-04-20 | Y |
| Hire sufficient dietary support personnel. | Health | 2017-11-06 | 2017-11-21 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-06 | 2017-11-21 | 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 | 2017-05-15 | 2017-06-01 | N |
| Have an externally vented heating system. | Fire Safety | 2017-05-15 | 2017-06-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-05-15 | 2017-06-01 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-05-18 | 2017-06-01 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-05-18 | 2017-06-01 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-05-18 | 2017-06-01 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-05-18 | 2017-06-01 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2017-03-30 | 2017-04-14 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-02-23 | 2017-02-28 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-02-23 | 2017-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-02-07 | 2017-02-28 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-12-21 | 2017-02-28 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-12-21 | 2017-02-28 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-12-21 | 2017-02-28 | Y |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2016-12-21 | 2017-02-28 | Y |
| Try to resolve each resident's complaints quickly. | Health | 2016-12-01 | 2017-02-28 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-12-01 | 2017-02-28 | Y |
| Hire sufficient dietary support personnel. | Health | 2016-12-01 | 2017-02-28 | Y |
| Provide special eating equipment and utensils for each resident who needs them. | Health | 2016-12-01 | 2017-02-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-04-29 | 2016-05-14 | Y |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-03-04 | 2016-04-08 | N |
| Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2016-03-04 | 2016-04-08 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-03-04 | 2016-04-08 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2016-03-03 | 2016-04-08 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2016-03-03 | 2016-04-08 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-03-03 | 2016-04-08 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-03-03 | 2016-04-08 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-03-03 | 2016-04-08 | N |
