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THE LUTHERAN HOME
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Details
Costs
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CMS Inspection Results
The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.
- 03/27/2007 Health Survey for THE LUTHERAN HOME
| Administration | ||
| Deficiency | Scope | Level of Harm |
| Have a detailed, written plan for disasters and emergencies. | Widespread | Minimal harm or potential for actual harm |
| Keep accurate and appropriate medical records. | Pattern | Minimal harm or potential for actual harm |
| Environmental | ||
| Deficiency | Scope | Level of Harm |
| Make sure that the nursing home area is free of dangers that cause accidents. | Isolated | Actual harm |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable. | Pattern | Minimal harm or potential for actual harm |
| Provide needed housekeeping and maintenance. | Pattern | Minimal harm or potential for actual harm |
| Make sure that staff members wash their hands when needed. | Pattern | Minimal harm or potential for actual harm |
| Mistreatment | ||
| Deficiency | Scope | Level of Harm |
| 1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Pattern | Minimal harm or potential for actual harm |
| Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. | Isolated | Minimal harm or potential for actual harm |
| Nutrition and Dietary | ||
| Deficiency | Scope | Level of Harm |
| Provide special eating equipment and utensils for each resident who needs them. | Isolated | Minimal harm or potential for actual harm |
| Pharmacy Service | ||
| Deficiency | Scope | Level of Harm |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Isolated | Minimal harm or potential for actual harm |
| 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | Isolated | Minimal harm or potential for actual harm |
| Quality Care | ||
| Deficiency | Scope | Level of Harm |
| Give professional services that meet a professional standard of quality. | Pattern | Minimal harm or potential for actual harm |
| Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. | Isolated | Minimal harm or potential for actual harm |
| Resident Rights | ||
| Deficiency | Scope | Level of Harm |
| Provide services to meet the needs and preferences of each resident. | Isolated | Minimal harm or potential for actual harm |
- 03/21/2007 Fire Safety Survey for THE LUTHERAN HOME
| Automatic Sprinkler Systems | ||
| Deficiency | Scope | Level of Harm |
| an approved automatic sprinkler system connected to the fire alarm system. | Isolated | Minimal harm or potential for actual harm |
| Building Contruction | ||
| Deficiency | Scope | Level of Harm |
| a two-hour-resistant firewall in common walls. | Widespread | Minimal harm or potential for actual harm |
| Building Service Equipment | ||
| Deficiency | Scope | Level of Harm |
| properly protected cooking facilities. | Widespread | Minimal harm or potential for actual harm |
| Electrical | ||
| Deficiency | Scope | Level of Harm |
| properly installed electrical wiring and equipment. | Pattern | Minimal harm or potential for actual harm |
| Hazardous Area | ||
| Deficiency | Scope | Level of Harm |
| construction that can resist fire for one hour or an approved fire extinguishing system. | Pattern | Minimal harm or potential for actual harm |
| properly installed hallway dispensers for alcohol-based hand rub. | Pattern | Minimal harm or potential for actual harm |
| Illumination and Emergency Power | ||
| Deficiency | Scope | Level of Harm |
| proper backup exit lighting. | Widespread | Minimal harm or potential for actual harm |
| Medical Gases and Anesthetizing Areas | ||
| Deficiency | Scope | Level of Harm |
| proper medical gas storage and administration areas. | Pattern | Minimal harm or potential for actual harm |
| Miscellaneous | ||
| Deficiency | Scope | Level of Harm |
| fire safety features required by current fire safety codes. | Widespread | Minimal harm or potential for actual harm |
- 03/30/2006 Fire Safety Survey for THE LUTHERAN HOME
| Automatic Sprinkler Systems | ||
| Deficiency | Scope | Level of Harm |
| an approved automatic sprinkler system connected to the fire alarm system. | Widespread | Minimal harm or potential for actual harm |
| Electrical | ||
| Deficiency | Scope | Level of Harm |
| properly installed electrical wiring and equipment. | Pattern | Minimal harm or potential for actual harm |
| Illumination and Emergency Power | ||
| Deficiency | Scope | Level of Harm |
| emergency lighting that can last at least 1 1/2 hours. | Pattern | Minimal harm or potential for actual harm |
| Smoking Regulations | ||
| Deficiency | Scope | Level of Harm |
| posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed. | Widespread | Minimal harm or potential for actual harm |
- 03/06/2006 Health Survey for THE LUTHERAN HOME
| Mistreatment | ||
| Deficiency | Scope | Level of Harm |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Isolated | Minimal harm or potential for actual harm |
| Pharmacy Service | ||
| Deficiency | Scope | Level of Harm |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Pattern | Minimal harm or potential for actual harm |
| Quality Care | ||
| Deficiency | Scope | Level of Harm |
| Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion. | Isolated | Actual harm |
| Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. | Isolated | Minimal harm or potential for actual harm |
| Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. | Isolated | Minimal harm or potential for actual harm |
| Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable. | Isolated | Minimal harm or potential for actual harm |
| Give each resident care and services to get or keep the highest quality of life possible. | Isolated | Minimal harm or potential for actual harm |
| Give professional services that meet a professional standard of quality. | Isolated | Minimal harm or potential for actual harm |
| Resident Assessment | ||
| Deficiency | Scope | Level of Harm |
| Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | Isolated | Minimal harm or potential for actual harm |
| Make a complete assessment that covers all questions for areas that are listed in official regulations. | Pattern | Potential for minimal harm |
| Resident Rights | ||
| Deficiency | Scope | Level of Harm |
| Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. | Isolated | Minimal harm or potential for actual harm |
- 05/19/2005 Health Survey for THE LUTHERAN HOME
| Environmental | ||
| Deficiency | Scope | Level of Harm |
| Provide needed housekeeping and maintenance. | Isolated | Minimal harm or potential for actual harm |
| Nutrition and Dietary | ||
| Deficiency | Scope | Level of Harm |
| Make sure that residents are well nourished. | Pattern | Minimal harm or potential for actual harm |
| Quality Care | ||
| Deficiency | Scope | Level of Harm |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Isolated | Actual harm |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Isolated | Minimal harm or potential for actual harm |
| Resident Rights | ||
| Deficiency | Scope | Level of Harm |
| Allow residents to easily see the results of the nursing home's most recent survey. | Widespread | Potential for minimal harm |
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