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Deficiency Records for Lutheran Living Senior Campus
A list of the most recent deficiencies for Lutheran Living Senior Campus. 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 Lutheran Living Senior Campus. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-05 | 2023-11-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-05 | 2023-11-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-05 | 2023-11-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-05 | 2023-11-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-05 | 2023-11-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-05 | 2023-11-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-05 | 2023-11-13 | N |
| Post nurse staffing information every day. | Health | 2023-10-05 | 2023-11-13 | 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 | 2023-10-05 | 2023-11-13 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-10-05 | 2023-11-13 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-05 | 2023-11-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-05 | 2023-11-13 | 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 | 2023-10-05 | 2023-11-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-05 | 2023-11-13 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-10-05 | 2023-11-13 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-05 | 2023-11-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-05 | 2023-11-13 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-05 | 2023-11-13 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-10-05 | 2023-11-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-05 | 2023-10-30 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2023-10-05 | 2023-10-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-05 | 2023-10-30 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-28 | 2023-10-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-09-28 | 2023-10-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-28 | 2023-10-05 | 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 | 2023-09-28 | 2023-10-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-26 | 2023-05-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-26 | 2023-05-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-15 | 2022-07-20 | 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 | 2022-06-15 | 2022-07-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-15 | 2022-07-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-15 | 2022-07-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-15 | 2022-07-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-15 | 2022-07-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-15 | 2022-07-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-15 | 2022-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-15 | 2022-07-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-15 | 2022-07-20 | Y |
| 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 | 2022-06-09 | 2022-06-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-09 | 2022-06-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-01 | 2019-08-29 | 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 | 2019-08-01 | 2019-08-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-01 | 2019-08-29 | 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 | 2019-08-01 | 2019-08-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-01 | 2019-08-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-01 | 2019-08-29 | 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 | 2019-08-01 | 2019-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-01 | 2019-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-01 | 2019-08-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-08-05 | 2019-08-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-05 | 2019-08-08 | N |
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