Deficiency Records for Lutheran Life Villages
Updated as of February 01, 2019
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 |