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Deficiency Records for Spiritrust Lutheran The Village at Sprenkle Drive
A list of the most recent deficiencies for Spiritrust Lutheran The Village at Sprenkle Drive. 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 Spiritrust Lutheran The Village at Sprenkle Drive. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-11-18 | 2025-01-17 | 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 | 2024-11-18 | 2025-01-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-11-18 | 2025-01-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-11-06 | 2024-12-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-11-06 | 2024-12-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-11-06 | 2024-12-28 | 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 | 2024-11-06 | 2024-12-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-11-06 | 2024-12-28 | 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 | 2024-11-06 | 2024-12-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-11-06 | 2024-12-28 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-11-06 | 2024-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-11-06 | 2024-12-28 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-11-06 | 2024-12-28 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-11-06 | 2024-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-11-06 | 2024-12-28 | N |
| Meet other general requirements. | Fire Safety | 2024-01-16 | 2024-03-13 | N |
| Use approved construction type or materials. | Fire Safety | 2024-01-16 | 2024-03-13 | 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 | 2024-01-16 | 2024-03-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-16 | 2024-03-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-16 | 2024-03-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-04 | 2024-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-04 | 2024-03-01 | 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 | 2024-01-04 | 2024-03-01 | N |
| Provide or obtain dental services for each resident. | Health | 2024-01-04 | 2024-03-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-30 | 2023-03-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-19 | 2023-03-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-19 | 2023-03-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-19 | 2023-03-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-19 | 2023-03-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-24 | 2022-09-30 | Y |
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