Lutheran Life Villages

In the surveyor’s words

From the most serious findings on record at Lutheran Life Villages, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Aug 29, 2025

  Based on observation, interview and record review, the facility failed to date medications when opened, failed to ensure treatments were placed in treatment cart, failed to ensure medication carts were free from loose pills/debris, and failed to record temperature logs for the Emergency Drug Kit/narcotic refrigerator in medication room, in 4 of 4 medication carts and 1 of 1 medication storage rooms reviewed. Findings include:During an observation on 08/26/2025 at 9:52 AM on the 100 hall medication carts with the Director of Nursing (DON) was observed. At 9:55 AM Resident 34 had an opened medication of Albuterol sulfate 30 mcg inhaler dated 1-24-25, and then another opened Albuterol sulfate 30 mcg inhaler with an opened date of 4/4/25. […]

• No harm, potential for more than minimal, patternF657Nov 9, 2022

  Based on observation, interview and record review, the facility failed to ensure care plans were updated to accommodate changes for 4 of 4 residents reviewed (Resident 19, Resident 40, Resident 53, and Resident 77). Findings include: 1. During a record review conducted on 11/2/22 at 11:21 AM, a Minimum Data Set (MDS) dated [DATE] indicated Resident 19 had diagnoses including COVID-19, non-pressure chronic ulcer of other part of right foot, unspecified severity, and peripheral vascular disease. An interview was deferred due to positive COVID-19 status. A physician's order dated 10/21/22 gave instructions to wash the right great toe and apply betadine for enzymatic debridement. […]

• No harm, potential for more than minimal, patternF812Nov 9, 2022

  Based on observation, interview and record review, the facility failed to ensure cookware was properly air dried and stored. 103 of 104 residents residing in the facility consume food from the kitchen. Findings include: During an observation with the Dietary Manager on 11/2/22 at 9:06 AM, metal pans used to contain food were observed stacked together on a storage rack. Upon separation of the pans, water dripped from each separated pan. During an interview with the Dietary Manager on 11/2/22 at 9:06 AM, he indicated the pans should be air dried prior to stacking. A current policy last revised 11/10/09 titled Handling Cleaned Equipment and Utensils indicated pots, pans and utensils should be air dried before being stored. 3.1-21(i)(3)

• No harm, potential for more than minimal, patternF758Oct 1, 2021

  Based on record review and interview, the facility failed to ensure the care plan was followed for monitoring and documenting side effects and the effectiveness of psychoactive medication for 5 of 5 residents (Resident 3, Resident Resident 44, Resident 88, Resident 90, and Resident 205) reviewed. Findings include: 1. Resident 44's record was reviewed on 9/24/21 at 2:06 P.M. Diagnoses included, but were not limited to, [CONDITION(S)]. The Significant Change MDS (Minimum Data Set) assessment dated [DATE] indicated the resident was not interviewable. The Physician's Order dated 5/8/21 indicated give [MEDICATION(S)] (antidepressant) 20 mg (milligrams) 1 tablet 1 time a day. […]

• No harm, potential for more than minimal, patternF921Jun 30, 2021

  Based on observation, record review, and interview, the facility failed to ensure maintenance was completed for of rooms observed, and for 1 of 1 water fountain removal site observed. (Room 110, Room 113, Room 118, Room 315, and Room 419) Findings include During an observation in room 315 on 6/29/21 at 2:45 P.M., when the bed from the wall, there was a hole in the dry wall toward the window corner. The hole was approximately 8.5 x 6 inches; the dry wall below the hole but right above the baseboard appeared to be bulging. Along the top of the baseboard and toward the front of the room, there were 2 more holes; one approximately 5 x 2 inches and the other approximately 5 x 1.5 inches. […]