A list of the most recent deficiencies for Lutheran Home. 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-19 | 2023-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-19 | 2023-11-17 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-09 | 2023-01-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-12-09 | 2023-01-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-08-31 | 2021-09-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-31 | 2021-09-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-31 | 2021-09-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-31 | 2021-09-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-31 | 2021-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-31 | 2021-09-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-08-31 | 2021-09-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-23 | 2021-09-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-23 | 2021-09-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-23 | 2021-09-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-12 | 2019-10-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-12 | 2019-10-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-12 | 2019-10-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-12 | 2019-10-12 | 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 | 2019-09-12 | 2019-10-12 | 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 | 2019-09-12 | 2019-10-12 | 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 | 2019-09-12 | 2019-10-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-11 | 2019-10-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-11 | 2019-10-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-11 | 2019-10-12 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-08-23 | Not Fixed | N |
