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 simulated fire drills held at unexpected times. | Fire Safety | 2023-10-24 | 2023-11-24 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-24 | 2023-11-24 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-24 | 2023-11-24 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-02 | 2023-10-03 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-14 | 2023-02-08 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-14 | 2023-02-08 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-14 | 2023-02-08 | 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 | 2022-11-09 | 2022-11-10 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-09 | 2022-11-10 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-09 | 2022-11-10 | N |
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 |