Deficiency Records for Spiritrust Lutheran The Village at Sprenkle Drive
Updated as of March 01, 2024
A list of the most recent deficiencies for Spiritrust Lutheran The Village at Sprenkle Drive. 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2024-01-16 | 2024-03-13 | N |
| Use approved construction type or materials. | Fire Safety | 2024-01-16 | 2024-03-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-16 | 2024-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-16 | 2024-03-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-04 | 2024-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-04 | 2024-03-01 | 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 | 2024-01-04 | 2024-03-01 | N |
| Provide or obtain dental services for each resident. | Health | 2024-01-04 | 2024-03-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-16 | 2024-02-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-19 | 2023-03-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-19 | 2023-03-06 | 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 | 2023-01-19 | 2023-03-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-19 | 2023-03-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-24 | 2022-09-30 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-24 | 2022-03-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-24 | 2022-03-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-10 | 2022-03-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-13 | 2022-03-04 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-01-13 | 2022-03-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-13 | 2022-03-04 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-13 | 2022-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-13 | 2022-03-04 | N |
