A list of the most recent deficiencies for Lutheran Life Villages. 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? |
|---|---|---|---|---|
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-24 | 2023-11-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-24 | 2023-11-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-24 | 2023-11-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-02 | 2023-10-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-14 | 2023-02-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-14 | 2023-02-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-14 | 2023-02-08 | 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 | 2022-11-09 | 2022-11-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-09 | 2022-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-09 | 2022-11-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-15 | 2021-11-30 | 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 | 2021-10-01 | 2021-10-22 | 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 | 2021-10-01 | 2021-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-01 | 2021-10-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-10-01 | 2021-10-22 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-10-01 | 2021-10-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-30 | 2021-07-03 | Y |
