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Deficiency Records for St John Lutheran Home
A list of the most recent deficiencies for St John 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 St John 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 timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-04-17 | 2024-06-07 | 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 | 2024-04-17 | 2024-06-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-17 | 2024-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-04-17 | 2024-06-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-16 | 2024-06-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-04-16 | 2024-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-04-16 | 2024-06-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-04-16 | 2024-06-07 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-03-08 | 2023-05-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-08 | 2023-05-03 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-03-08 | 2023-05-03 | Y |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-08 | 2023-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-08 | 2023-04-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-08 | 2023-04-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-08 | 2023-04-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-08 | 2023-04-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-08 | 2023-04-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-08 | 2023-03-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-08 | 2023-03-10 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-23 | 2022-04-29 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2021-09-22 | 2021-12-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-09-24 | 2021-12-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-24 | 2021-12-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-24 | 2021-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-22 | 2021-12-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-09-24 | 2021-11-26 | 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 | 2021-09-24 | 2021-11-26 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-09-24 | 2021-11-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-09-22 | 2021-11-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-22 | 2021-11-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-09-24 | 2021-11-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-22 | 2021-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-22 | 2021-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-24 | 2021-10-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-24 | 2021-10-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-22 | 2021-10-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-09-22 | 2021-10-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-09-22 | 2021-10-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-22 | 2021-10-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-22 | 2021-10-21 | N |
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