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Deficiency Records for Salem Lutheran Home
A list of the most recent deficiencies for Salem 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 Salem 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? |
|---|---|---|---|---|
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-15 | 2024-05-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-15 | 2024-05-31 | Y |
| 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 | 2023-06-06 | 2023-06-26 | N |
| Respond appropriately to all alleged violations. | Health | 2023-06-06 | 2023-06-26 | 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 | 2023-06-06 | 2023-06-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-06 | 2023-06-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-06 | 2023-06-26 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-06 | 2023-06-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-06 | 2023-06-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-06 | 2023-06-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-06 | 2023-06-26 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-06 | 2023-06-26 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-06-06 | 2023-06-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-06 | 2023-06-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-06 | 2023-06-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-06 | 2023-06-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-06 | 2023-06-26 | Y |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-06-07 | 2023-06-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-07 | 2023-06-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-07 | 2023-06-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-07 | 2023-06-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-07 | 2023-06-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-07 | 2023-06-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-07 | 2023-06-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-01 | 2022-09-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-01 | 2022-09-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-24 | 2022-04-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-24 | 2022-04-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-04-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-14 | 2022-04-18 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-02-22 | 2022-03-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-22 | 2022-03-08 | 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 | 2022-02-22 | 2022-03-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-02-22 | 2022-03-04 | 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 | 2022-02-24 | 2022-03-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-22 | 2022-03-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-02-22 | 2022-02-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-02-24 | 2022-02-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-22 | 2022-02-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-22 | 2022-02-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-22 | 2022-02-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-22 | 2022-02-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-22 | 2022-02-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-24 | 2022-02-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-24 | 2022-02-24 | 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 | 2022-02-24 | 2022-02-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-24 | 2022-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-24 | 2022-02-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2020-02-06 | 2020-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-06 | 2020-02-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-06 | 2020-02-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-06 | 2020-02-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-02-06 | 2020-02-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-06 | 2020-02-20 | 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 | 2020-02-06 | 2020-02-18 | N |
| Use approved construction type or materials. | Fire Safety | 2020-02-06 | 2020-02-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-06 | 2020-02-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-06 | 2020-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-06 | 2020-02-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2020-01-30 | 2020-02-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-30 | 2020-02-14 | 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 | 2020-01-30 | 2020-02-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-30 | 2020-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-30 | 2020-02-14 | 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 | 2020-01-30 | 2020-02-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-01-30 | 2020-02-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-30 | 2020-02-11 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2020-02-06 | 2020-02-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-06 | 2020-02-06 | N |
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