Deficiency Records for Lutheran Life Villages
Updated as of July 01, 2022
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? |
---|---|---|---|---|
Implement emergency and standby power systems. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Meet other general requirements that are deficient. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Construct fire resistant interior walls. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-15 | 2021-11-30 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-01 | 2021-10-22 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-10-01 | 2021-10-22 | N |
Provide and implement an infection prevention and control program. | Health | 2021-10-01 | 2021-10-22 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-10-01 | 2021-10-22 | Y |
Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-10-01 | 2021-10-22 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-06-30 | 2021-07-03 | Y |
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 |