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Deficiency Records for Faith Lutheran Home
A list of the most recent deficiencies for Faith 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 Faith 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? |
|---|---|---|---|---|
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-05-08 | 2024-06-13 | 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 | 2024-05-15 | 2024-06-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-05-15 | 2024-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-15 | 2024-06-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-15 | 2024-06-12 | N |
| Ensure that smoke control systems are tested and documented in accordance with established engineering principles. | Fire Safety | 2024-05-15 | 2024-06-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-08 | 2024-06-07 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-05-08 | 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 | 2024-05-08 | 2024-06-07 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-05-08 | 2024-06-07 | 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 | 2024-05-08 | 2024-06-07 | Y |
| 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 | 2023-05-30 | 2023-06-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-30 | 2023-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-30 | 2023-06-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-30 | 2023-06-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-30 | 2023-06-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-23 | 2023-06-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-23 | 2023-06-15 | 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 | 2023-05-23 | 2023-06-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-23 | 2023-06-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-16 | 2022-06-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-05-16 | 2022-06-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-05-16 | 2022-06-30 | N |
| Develop a communication plan. | Fire Safety | 2022-05-16 | 2022-06-30 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-05-16 | 2022-06-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-05-16 | 2022-06-30 | 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 | 2022-05-16 | 2022-06-30 | 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 | 2022-05-16 | 2022-06-30 | 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 | 2022-05-16 | 2022-06-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-16 | 2022-06-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-16 | 2022-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-16 | 2022-06-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-11 | 2022-06-14 | 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 | 2022-05-11 | 2022-06-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-11 | 2022-06-14 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-05-11 | 2022-06-14 | 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 | 2022-05-11 | 2022-06-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-05-11 | 2022-06-14 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-05-11 | 2022-06-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-11 | 2022-06-14 | Y |
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