Deficiency Records for Lutheran Life Villages
Updated as of September 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 |
