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, patternF758Apr 29, 2022

  Based on record review and interview the facility failed to ensure monitoring of [CONDITION(S)] medications for 5 of 6 residents reviewed. (Resident 14, Resident 2, Resident 59, Resident 79, and Resident 45) Findings include: 1. In a record review for Resident 14, began on 4/27/22 at 9:45 AM, diagnoses included: anxiety disorder, sedative dependence, psychoactive substance abuse, major depressive disorder, [CONDITION(S)] disorder, personality disorder, and hallucinations. Resident 14 had a BIMS (Brief Interview Mental Status) score of 9 according to most recent assessment dated [DATE]. […]

• No harm, potential for more than minimal, isolatedF697Mar 3, 2026

  Based on interviews and record reviewed, the facility failed to ensure non-pharmacological interventions were completed. For 1 of 1 resident reviewed. (Resident 10)Findings include:Resident 10's record was reviewed on 2/25/26 at 1:13 PM. Diagnosis included, chronic kidney disease, stage 4. A review of Resident 10's current significant change minimum data set indicated their BIMS (Basic Interview for Mental Status) score was 12.A review of Resident 10's current Care plan, dated 2/6/26, indicated a focus of chronic pain related to osteoarthritis, age-related debility, gout, GERD. The goals included the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. […]

• No harm, potential for more than minimal, isolatedF684Mar 19, 2025

  Based on interview and record review the facility failed to ensure physician orders were followed though regarding a laboratory blood draw for 1 of 1 residents reviewed. (Resident 8) Findings include: A record review began on 3/14/25 at 2:04 PM. Resident 8's diagnosis included Alzheimer's disease, bipolar disorder, and depression. A review of the physician orders indicated the following: Lamotrigine oral tablet 150 MG (milligrams) (Lamotrigine), give 1 tablet by mouth one time a day related to Bipolar disorder, current episode depressed, mild or moderate severity, unspecified. Start date 7/26/24. Lamotrigine level every 6 months, due 8/28/24: one time only for labs until 8/28/24 at 11:59 PM. order date 2/26/24. start date 8/28/24. […]

• No harm, potential for more than minimal, isolatedF694Mar 19, 2025

  Based on observation, interview and record review, the facility failed to ensure vascular access device was monitored and maintained for 1 of 1 resident reviewed (Resident 52). Findings include: On 3/14/25 at 10:25 AM, Resident 52 was observed sitting in their wheelchair in their room. Resident 52's right lower arm and right hand were observed to be swollen. Resident 52's right lower arm and right hand were observed to be red and purple in color. In an interview, on 3/14/25 at 10:40 AM, Resident 52 indicated their right arm and right hand were swollen and bruised due to a problem with an intravenous (IV) line. Resident 52 indicated an IV line had to be removed from their right arm. Resident 52 raised their left shirt sleeve. A transparent dressing above the left elbow bend was observed. […]

• No harm, potential for more than minimal, isolatedF756Mar 19, 2025

  Based on interview and record review, the facility failed to ensure pharmacy recommendations were followed through for 1 of 5 residents reviewed. (Resident 22) Findings include: A record review began on 3/18/25 at 9:14 AM. Resident 22's diagnosis included, chronic obstructive pulmonary disease. A review of the physician orders indicated: Methocarbamol oral tablet (methocarbamol) give 250 mg ( milligrams) by mouth every 8 hours as needed for Muscle relaxer. Start date 12/9/24. A review of the pharmacy consultation report dated February 25, 2025 through February 26, 2025: indicated Resident 22 received a muscle relaxant, Methocarbarnol. The medication had not been used since 12/18/24. Recommendation: please discontinue Methocarbmol. […]