Deficiency Records for Lutheran Life Villages
Updated as of March 01, 2018
This is not the most recent data for Lutheran Life Villages. For the most recent information, click here.
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? |
---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-05-26 | 2017-06-25 | Y |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-05-26 | 2017-06-25 | Y |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-05-26 | 2017-06-25 | Y |
Meet other general requirements. | Fire Safety | 2017-04-17 | 2017-05-04 | N |
Have protected exits that allow the resident to escape the building. | Fire Safety | 2017-04-17 | 2017-05-04 | 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 | 2017-04-17 | 2017-05-04 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-04-17 | 2017-05-04 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2017-04-17 | 2017-05-04 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-04-17 | 2017-05-04 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2017-04-17 | 2017-05-04 | N |
Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2017-04-17 | 2017-05-04 | N |
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-31 | 2017-04-30 | N |
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-03-31 | 2017-04-30 | N |
1) Hire only people with 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. | Health | 2017-03-31 | 2017-04-30 | Y |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-31 | 2017-04-30 | Y |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-31 | 2017-04-30 | Y |
Ensure that all full-time nurse aides employed for more than 4 months are fully trained and competent to provide nursing and nursing-related services, as defined by Federal requirements. | Health | 2017-03-31 | 2017-04-30 | Y |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-31 | 2017-04-30 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-03-31 | 2017-04-03 | Y |
Corridor and hallway doors that block smoke. | Fire Safety | 2016-04-04 | 2016-05-04 | N |
Proper stairway enclosures and vertical shafts. | Fire Safety | 2016-04-04 | 2016-05-04 | N |
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-04-04 | 2016-05-04 | N |
A written emergency evacuation plan. | Fire Safety | 2016-04-04 | 2016-05-04 | N |
Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-04-04 | 2016-05-04 | N |
Properly sized and located linen or trash receptacles. | Fire Safety | 2016-04-04 | 2016-05-04 | N |
Proper medical gas storage and administration areas. | Fire Safety | 2016-04-04 | 2016-05-04 | N |
Have other fire safety features required by fire safety codes. | Fire Safety | 2016-04-04 | 2016-05-04 | N |
Properly installed electrical wiring and equipment. | Fire Safety | 2016-04-04 | 2016-05-04 | N |
Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2016-03-03 | 2016-04-01 | N |
Provide activities to meet the interests and needs of each resident. | Health | 2016-03-03 | 2016-04-01 | N |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-03-03 | 2016-04-01 | N |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-03-03 | 2016-04-01 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-03-03 | 2016-04-01 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-03-03 | 2016-04-01 | N |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-03-03 | 2016-04-01 | Y |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-06-30 | 2015-07-17 | Y |
A two-hour-resistant firewall separation. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
Portable fire extinguishers. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
Restrictions on the use of flammable curtains. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
Have other fire safety features required by fire safety codes. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
Properly installed electrical wiring and equipment. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
An elevator that firefighters can control in the event of a fire. | Fire Safety | 2015-02-04 | 2015-04-15 | N |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2015-02-12 | 2015-03-16 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-02-12 | 2015-03-16 | N |
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-02-12 | 2015-03-16 | N |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2015-02-12 | 2015-03-16 | N |
Provide routine and 24-hour emergency dental care for each resident. | Health | 2015-02-12 | 2015-03-16 | N |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2015-02-12 | 2015-03-16 | N |