Deficiency Records for Spiritrust Lutheran The Village at Utz Terrace
Updated as of March 01, 2024
A list of the most recent deficiencies for Spiritrust Lutheran The Village at Utz Terrace. 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 each resident receives an accurate assessment. | Health | 2023-05-25 | 2023-06-26 | 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 | 2023-05-25 | 2023-06-26 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-05-25 | 2023-06-26 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-05-25 | 2023-06-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-11 | 2023-06-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-15 | 2023-03-16 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-09 | 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 | 2022-06-09 | 2022-07-13 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-06-09 | 2022-07-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-09 | 2022-07-13 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-06-09 | 2022-07-13 | 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 | 2022-06-09 | 2022-07-13 | 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 | 2022-06-09 | 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 | 2022-06-09 | 2022-07-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-12-16 | 2022-01-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-29 | 2021-09-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-29 | 2021-09-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-29 | 2021-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-29 | 2021-09-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-29 | 2021-09-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-07-29 | 2021-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-29 | 2021-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-29 | 2021-09-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-29 | 2021-08-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-29 | 2021-08-28 | N |
