Deficiency Records for Lutheran Life Villages
Updated as of March 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 |
