Lakeshore Lutheran Home

Total Number of Beds: 151	Percent of Occupied Beds: 93%
Total Number of Residents: 140	Located Within a Hospital: No
Type of Ownership: Non profit - Church related	Multiple Nursing Homes by Same Owner: Yes
Councils the Nursing Home Participates in: Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 08/22/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.74

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.91

Number of CNA Hours per Nursing Home Resident per Day: 2.59

Number of Staff Hours per Nursing Home Resident per Day: 4.24

Nursing Home Resident Information**:

Percent of Low-Risk Residents Who Have Pressure Sores: 6%
Percent of Short-Stay Residents With Pressure Sores: 11%
Percent of High-Risk Residents Who Have Pressure Sores: 14%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 48%
Percent of Residents Who Have Moderate to Severe Pain: 7%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 18%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 1%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 18%
Percent of Residents Who are More Depressed or Anxious: 19%
Percent of Short-Stay Residents With Delirium: 1%
Percent of Residents Who Were Physically Restrained: 8%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 52%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 4%
Percent of Residents With a Urinary Tract Infection: 9%
** Details Last Reported on: 8/22/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-05-11	2001-06-21	Resident Rights Deficiencies	Keep each resident's personal and medical records private and confidential.	Isolated	Actual harm
2001-05-11	2001-06-21	Resident Rights Deficiencies	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
2001-05-11	2001-06-21	Environmental Deficiencies	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
2001-05-11	2001-06-21	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
2001-05-11	2001-06-21	Resident Assessment Deficiencies	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
2001-05-11	2001-06-21	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
2001-05-11	2001-06-21	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
2001-05-11	2001-06-21	Quality Care Deficiencies	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	Isolated	Minimal harm or potential for actual harm
2001-05-11	2001-06-21	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Minimal harm or potential for actual harm
2001-05-11	2001-06-21	Quality Care Deficiencies	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
2001-05-11	2001-06-21	Pharmacy Service Deficiencies	Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing.	Isolated	Minimal harm or potential for actual harm
2002-07-15	2002-08-14	Resident Rights Deficiencies	Keep each resident's personal and medical records private and confidential.	Isolated	Actual harm
2002-07-15	2002-08-14	Resident Rights Deficiencies	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
2002-07-15	2002-08-14	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
2002-07-15	2002-08-14	Resident Rights Deficiencies	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Pattern	Minimal harm or potential for actual harm
2002-07-15	2002-08-14	Environmental Deficiencies	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
2002-07-15	2002-08-14	Resident Assessment Deficiencies	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Actual harm
2002-07-15	2002-08-14	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Actual harm
2002-07-15	2002-08-14	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
2002-07-15	2002-08-14	Quality Care Deficiencies	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
2002-07-15	2002-08-14	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
2002-07-15	2002-08-14	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Pattern	Actual harm
2002-07-15	2002-08-14	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
2003-08-22	2003-11-04	Resident Rights Deficiencies	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
2003-08-22	2003-11-04	Mistreatment Deficiencies	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
2003-08-22	2003-10-14	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
2003-08-22	2003-11-04	Resident Rights Deficiencies	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
2003-08-22	2003-11-04	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
2003-08-22	2003-10-14	Resident Assessment Deficiencies	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
2003-08-22	2003-10-14	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
2003-08-22	2003-10-14	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
2003-08-22	2003-11-04	Quality Care Deficiencies	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
2003-08-22	2003-10-14	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Minimal harm or potential for actual harm
2003-08-22	2003-10-14	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
2003-08-22	2003-11-04	Environmental Deficiencies	Make sure that staff members wash their hands when needed.	Pattern	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.