Saint Luke Lutheran Home

Survey Date: Friday, March 7, 2014
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 7, 2014
Survey Type: Health
Deficiency: F0412 (Provide or obtain dental services for each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 7, 2014
Survey Type: Health
Deficiency: F0356 (Post nurse staffing information/data on a daily basis.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Friday, March 7, 2014
Survey Type: Health
Deficiency: F0278 (Ensure each resident receives an accurate assessment by a qualified health professional.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0052 (An approved installation, maintenance and testing program for fire alarm systems.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0066 (Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0051 (A fire alarm system that can be heard throughout the facility.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0154 (Back-up procedures in place for a faulty automatic sprinkler system.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0018 (Corridor and hallway doors that block smoke.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0038 (Exits that are accessible at all times.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0211 (Properly installed hallway dispensers for alcohol-based hand rub.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0056 (An approved automatic sprinkler system connected to the fire alarm system.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0155 (An approved back-up procedure for a faulty fire alarm system.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0069 (Properly protected cooking facilities.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, March 5, 2014
Survey Type: Fire Safety
Deficiency: K0012 (Approved construction type or materials.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, April 15, 2014
The inspection cycle of deficiency: 1 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0172 (Allow residents to have visitors.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0332 (Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0329 (Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2))
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0156 (Give residents a notice of rights, rules, services and charges.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0431 (Maintain drug records and properly mark/label drugs and other similar products according to accepted)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0164 (Keep residents' personal and medical records private and confidential.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0167 (Allow residents to easily view the results of the nursing home's most recent inspection.)
Scope Severity Code: C
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0428 (At least once a month, have a licensed pharmacist review each resident's medication (s) and report a)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0280 (Allow residents the right to participate in the planning or revision of care and treatment.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0371 (Store, cook, and serve food in a safe and clean way.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0441 (Have a program that investigates, controls and keeps infection from spreading.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Thursday, December 6, 2012
Survey Type: Health
Deficiency: F0278 (Ensure each resident receives an accurate assessment by a qualified health professional.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 4, 2012
Survey Type: Fire Safety
Deficiency: K0017 (Corridors that are separated from use areas by walls constructed to limit the passage of smoke.)
Scope Severity Code: B
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 4, 2012
Survey Type: Fire Safety
Deficiency: K0144 (Weekly inspections and monthly testing of generators.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 4, 2012
Survey Type: Fire Safety
Deficiency: K0062 (Automatic sprinkler systems that have been maintained in working order.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 4, 2012
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Tuesday, December 4, 2012
Survey Type: Fire Safety
Deficiency: K0044 (Horizontal exits.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, January 22, 2013
The inspection cycle of deficiency: 2 (the deficiency was found on a standard inspection)

Survey Date: Wednesday, September 26, 2012
Survey Type: Health
Deficiency: F0456 (Keep all essential equipment working safely.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, October 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, September 26, 2012
Survey Type: Health
Deficiency: F0465 (Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staf)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, October 18, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, May 9, 2012
Survey Type: Health
Deficiency: F0365 (Provide food in a way that meets a resident's needs.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, June 28, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Tuesday, January 10, 2012
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, March 1, 2012
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, November 2, 2011
Survey Type: Health
Deficiency: F0412 (Provide or obtain dental services for each resident.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 22, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, November 2, 2011
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 22, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Wednesday, November 2, 2011
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, December 22, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a complaint inspection)

Survey Date: Friday, August 12, 2011
Survey Type: Fire Safety
Deficiency: K0051 (A fire alarm system that can be heard throughout the facility.)
Scope Severity Code: F
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, August 12, 2011
Survey Type: Fire Safety
Deficiency: K0044 (Horizontal exits.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Tuesday, November 1, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, August 12, 2011
Survey Type: Fire Safety
Deficiency: K0029 (Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishi)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, October 13, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, August 12, 2011
Survey Type: Fire Safety
Deficiency: K0147 (Properly installed electrical wiring and equipment.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, October 13, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Friday, August 12, 2011
Survey Type: Fire Safety
Deficiency: K0056 (An approved automatic sprinkler system connected to the fire alarm system.)
Scope Severity Code: E
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, October 13, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Health
Deficiency: F0425 (Provide routine and emergency drugs through a licensed pharmacist and only under the general supervi)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, October 13, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Health
Deficiency: F0323 (Ensure that a nursing home area is free from accident hazards and provide adequate supervision to pr)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, October 13, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Health
Deficiency: F0225 (1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) rep)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, October 13, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Health
Deficiency: F0314 (Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, October 13, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)

Survey Date: Thursday, August 11, 2011
Survey Type: Health
Deficiency: F0226 (Develop and implement policies for 1) screening and training employees; and the 2) prevention, ident)
Scope Severity Code: D
Deficiency Corrected: Deficient, Provider Has Date Of Correction
Date the deficiency was corrected: Thursday, October 13, 2011
The inspection cycle of deficiency: 3 (the deficiency was found on a standard inspection)