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.

• Actual harm, isolatedF689Mar 8, 2022

  Based on observation, interview and record review the facility failed to prevent multiple falls resulting in hospitalization with subarachnoid hemorrhage for 1 of 2 residents reviewed for accidents. (Resident 49.) The facility also failed to ensure proper water temperatures in 2 of 4 rooms observed (Rooms 204 and 208) affecting 3 residents. Findings include: 1. On 3/3/2022 at 4:00P.M., Resident 49's record was reviewed. Diagnoses included, but were not limited to, dementia, anxiety disorder, [CONDITION(S)], and hypertension. […]

• Actual harm, isolatedF690Mar 8, 2022

  Based on observation, interview, and record review the facility failed to ensure proper care of indwelling catheter for 1 of 2 residents reviewed (Resident 67) resulting in hospitalization . Findings include: In an observation, on 3/2/22 at 2:00 P.M., Resident 67 was lying in bed with his catheter tubing going down his leg under his pants. The tubing was pulled tightly as evidenced by his pants pulling up at the spot where the tubing catheter came out from under his clothing. There was no urine present in the tubing. The catheter bag was placed up close to Resident 67's shoulder area on handrail. The bag was above the bladder. The bag was not covered; the urine in the bag was yellow in color with no observed blood or sediment. […]

• No harm, potential for more than minimal, patternF880Jul 20, 2021

  Based on observation, interview and record review, the facility failed to ensure staaff maintained proper infection control procedures for 8 of 8 staff observed. Findings include: 1. During interview on 7/20/21 at 1:10 P.M., the Administrator indicated the facility had a Covid-19 positive resident on the [NAME] Street hallway who was waiting to be transferred to another facility, so all staff would be wearing N95 masks. During an observation on 7/20/21 at 1:30 P.M., on Oak Street hallway, Employees 2 and 4 did not have the bottom strap of the N95 around their heads and the strap was under their chins. Upon interview at the same time, Employee B indicated the mask was tight at the bottom and asked if they needed to have the strap on. […]

• No harm, potential for more than minimal, isolatedF761Mar 3, 2026

  Based on observation, interview, and record review, the facility failed to ensure medications were secured for 1 of 12 residents observed (Resident 48). Findings include:In an observation, on 02/24/2026 2:04 PM, a bottle of Tums (over the counter antacid tablets) about 20% full, 1 full bottle of Tums, 1 full box of Pepto Bismol (over the counter medication for gastro-intestinal discomfort) tablets and a jar of Vicks Vapo Rub (topical ointment) with visible fingerprints in the gel and a small amount missing were observed on a bedside table beside Resident 48 in her room. In an interview, on 02/24/2026 2:05 PM, Resident 48 indicated her family brought the full bottle of Tums and the box of Pepto Bismol that day. […]

• No harm, potential for more than minimal, isolatedF880Mar 3, 2026

  Based on observation, interview and record review, the facility failed to ensure hand hygiene procedures were maintained during direct resident care for 1 of 2 residents reviewed (Resident 36).Findings include:During a continuous observation on 2/26/26 at from 8:40 AM -8: 55 AM, Certified Nurse Aide (CNA) 5 was observed providing indwelling urinary catheter care for Resident 36.Resident 36 was in their bed with the head of the bed up in a sitting position. CNA 5 sanitized their hands, lowered the resident's bed and filled a basin with warm water. CNA 5 moved the bedside table, folded the resident's blanket down, removed their plush toy and placed the bed in lying position. CNA 5 applied gloves and unfastened Resident 36's brief. […]