Deficiency Records for The Lutheran Village at Miller's Grant
Updated as of April 01, 2024
A list of the most recent deficiencies for The Lutheran Village at Miller's Grant. 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? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-14 | 2023-01-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-14 | 2023-01-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-09-14 | 2022-12-14 | N |
| Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion. | Fire Safety | 2022-09-14 | 2022-12-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-14 | 2022-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-14 | 2022-12-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-14 | 2022-12-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-14 | 2022-12-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-14 | 2022-12-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-02 | 2022-10-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-02 | 2022-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-02 | 2022-10-31 | 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 | 2022-09-02 | 2022-10-31 | N |
| Post nurse staffing information every day. | Health | 2022-09-02 | 2022-10-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-09-02 | 2022-10-31 | 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 | 2022-09-02 | 2022-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-02 | 2022-10-31 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-02 | 2022-10-31 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-09-02 | 2022-10-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-02 | 2022-10-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-02 | 2022-10-31 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-13 | 2019-06-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-01-30 | 2018-03-20 | 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 | 2018-01-30 | 2018-03-20 | N |
