Deficiency Records for Lutheran Life Villages
Updated as of January 01, 2021
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? |
---|---|---|---|---|
Provide and implement an infection prevention and control program. | Health | 2020-09-22 | 2020-09-23 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-07-09 | 2020-08-10 | Y |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-24 | 2019-07-24 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-24 | 2019-07-24 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-24 | 2019-07-24 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-24 | 2019-07-24 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-16 | 2019-06-15 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-05-16 | 2019-06-15 | N |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-05-16 | 2019-06-15 | N |
Provide activities to meet all resident's needs. | Health | 2019-05-16 | 2019-06-15 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-16 | 2019-06-15 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-16 | 2019-06-15 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-16 | 2019-06-15 | 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 | 2019-05-16 | 2019-06-15 | N |
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 |
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 |
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 | 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 |
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 | 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 |
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 | N |
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 | N |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-31 | 2017-04-30 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-03-31 | 2017-04-03 | N |