Deficiency Records for St Luke Lutheran Community-Portage Lakes
Updated as of October 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? |
|---|---|---|---|---|
| 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 |
| Be properly staffed | 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 |
| 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 | 2019-09-09 | 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 | 2019-08-01 | 2019-09-09 | 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 | 2019-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-16 | 2019-08-12 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-07-16 | 2019-08-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-09 | 2019-06-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-06 | 2019-06-10 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-04-06 | 2019-06-10 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2019-04-06 | 2019-06-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-06 | 2019-06-10 | Y |
| Post nurse staffing information every day. | Health | 2019-04-06 | 2019-06-10 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-04-06 | 2019-06-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-06 | 2019-06-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-06 | 2019-06-10 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-04-06 | 2019-06-10 | Y |
| 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 |
