Deficiency Records for Lewis Memorial Christian Vlg

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Updated as of March 01, 2024

A list of the most recent deficiencies for Lewis Memorial Christian Vlg. 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?
Respond appropriately to all alleged violations. Health 2023-12-11 2023-12-18 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-12-11 2023-12-18 Y
Respond appropriately to all alleged violations. Health 2023-10-24 2023-12-18 Y
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2023-11-16 2023-12-01 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-11-16 2023-12-01 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-11-16 2023-12-01 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-11-16 2023-12-01 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2023-11-08 2023-11-22 Y
Reasonably accommodate the needs and preferences of each resident. Health 2023-10-24 2023-11-06 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-10-24 2023-11-06 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-10-24 2023-11-06 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-10-24 2023-11-06 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-09-15 2023-09-28 Y
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2023-08-30 2023-09-11 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-08-30 2023-09-11 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-30 2023-09-11 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-08-30 2023-09-11 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-06-23 2023-09-11 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-07-21 2023-07-27 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-06-23 2023-07-27 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-06-23 2023-07-27 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-06-23 2023-07-27 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-07-05 2023-07-20 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2023-07-05 2023-07-20 N
Develop a communication plan. Fire Safety 2023-07-05 2023-07-20 N
Establish emergency prep training and testing. Fire Safety 2023-07-05 2023-07-20 N
Provide properly protected cooking facilities. Fire Safety 2023-07-05 2023-07-20 N
Provide a written emergency evacuation plan. Fire Safety 2023-07-05 2023-07-20 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-07-05 2023-07-20 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-07-05 2023-07-20 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-07-05 2023-07-20 N
Have proper medical gas storage and administration areas. Fire Safety 2023-07-05 2023-07-20 N
Establish staff and initial training requirements. Fire Safety 2023-07-05 2023-07-19 N
Have exits that are accessible at all times. Fire Safety 2023-07-05 2023-07-17 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 2023-07-05 2023-07-17 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2023-07-05 2023-07-17 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-07-05 2023-07-14 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-02-23 2023-03-08 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-11-09 2022-11-10 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-10-13 2022-11-02 Y
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 2022-06-15 2022-06-28 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-06-15 2022-06-28 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-06-15 2022-06-28 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-06-15 2022-06-28 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2022-05-26 2022-06-09 N
Reasonably accommodate the needs and preferences of each resident. Health 2022-02-17 2022-03-01 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-09-09 2021-11-18 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2021-09-09 2021-11-18 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-08-27 2021-10-23 N
Address patient/client population and determine types of services needed. Fire Safety 2021-08-27 2021-10-12 N
Address subsistence needs for staff and patients. Fire Safety 2021-08-27 2021-10-12 N
Establish policies and procedures for sheltering. Fire Safety 2021-08-27 2021-10-12 N
Implement emergency and standby power systems. Fire Safety 2021-08-27 2021-10-12 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-08-27 2021-10-12 N
List the names and contact information of those in the facility. Fire Safety 2021-08-27 2021-09-26 N
Establish staff and initial training requirements. Fire Safety 2021-08-27 2021-09-26 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 2021-08-27 2021-09-26 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2021-08-27 2021-09-26 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-08-26 2021-09-24 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2021-08-26 2021-09-24 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2021-08-26 2021-09-24 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-08-26 2021-09-24 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2021-08-26 2021-09-24 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2021-08-26 2021-09-24 N
Create arrangements with other facilities to receive patients. Fire Safety 2021-08-27 2021-09-23 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-08-27 2021-09-21 N
Conduct testing and exercise requirements. Fire Safety 2021-08-27 2021-09-16 N
Provide properly protected cooking facilities. Fire Safety 2021-08-27 2021-09-15 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-08-27 2021-09-15 N
Establish policies and procedures for volunteers. Fire Safety 2021-08-27 2021-09-14 N
Provide emergency officials' contact information. Fire Safety 2021-08-27 2021-09-14 N
Provide primary/alternate means for communication. Fire Safety 2021-08-27 2021-09-14 N
Establish methods for sharing information. Fire Safety 2021-08-27 2021-09-14 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2021-08-27 2021-09-14 N
Provide family notifications of emergency plan. Fire Safety 2021-08-27 2021-09-14 N
Provide a written emergency evacuation plan. Fire Safety 2021-08-27 2021-09-14 N
Reasonably accommodate the needs and preferences of each resident. Health 2021-05-26 2021-06-25 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-05-26 2021-06-25 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-05-26 2021-06-25 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2021-05-26 2021-06-25 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-05-06 2021-06-25 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2021-05-06 2021-06-25 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-04-02 2021-06-25 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-03-16 2021-06-25 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-05-06 2021-06-11 Y