Deficiency Records for Lutheran Life Villages
Updated as of December 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? |
|---|---|---|---|---|
| Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Fire Safety | 2018-05-03 | 2018-06-21 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-05-03 | 2018-06-21 | 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 | 2018-05-03 | 2018-06-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-03 | 2018-06-21 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2018-05-03 | 2018-06-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-03 | 2018-06-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-05-03 | 2018-06-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-05-03 | 2018-06-21 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-05-03 | 2018-06-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-03 | 2018-06-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-13 | 2018-05-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-04-13 | 2018-05-11 | 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 | 2018-04-13 | 2018-05-11 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-04-13 | 2018-05-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-04-13 | 2018-05-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-13 | 2018-05-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-13 | 2018-05-11 | N |
| 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 |
