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Deficiency Records for Strawberry Point Lutheran Home
A list of the most recent deficiencies for Strawberry Point Lutheran Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Strawberry Point 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? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-06-13 | 2024-06-27 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-06-13 | 2024-06-27 | 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 | 2024-06-13 | 2024-06-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-13 | 2024-06-27 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-06-18 | 2024-06-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-18 | 2024-06-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-06-18 | 2024-06-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-18 | 2024-06-18 | N |
| Develop a communication plan. | Fire Safety | 2023-03-27 | 2023-04-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-27 | 2023-04-07 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-03-27 | 2023-04-07 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-03-27 | 2023-04-07 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-03-27 | 2023-04-07 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-03-27 | 2023-04-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-27 | 2023-04-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-22 | 2023-03-30 | N |
| Post nurse staffing information every day. | Health | 2023-03-22 | 2023-03-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-03-27 | 2023-03-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-03-27 | 2023-03-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-28 | 2023-01-16 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-30 | 2021-12-21 | N |
| 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 | 2021-11-30 | 2021-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-30 | 2021-12-08 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-30 | 2021-12-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-30 | 2021-12-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-30 | 2021-12-04 | 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 | 2021-11-30 | 2021-12-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-11-30 | 2021-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-30 | 2021-12-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-23 | 2021-11-24 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-11-23 | 2021-11-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-11-23 | 2021-11-24 | N |
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