Lutheran Life Villages

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure safety and prevention of abuse for 1 of 3 residents reviewed (Resident A). Findings include:Resident A's record was reviewed on 10/20/25 at 12:59 PM. Diagnoses included cognitive communication deficit and generalized anxiety disorder.Resident A's quarterly Minimum Data Set, (MDS) dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 7 (moderate cognitive loss).A summary of incident report, dated 10/9/25, indicated Resident A's spouse had made contact with the Resident A's face. The report indicated Adult Protective Services had been contacted. The report indicated Resident A's daughter was concerned about the spouse's decline and attempts to correct the spouse.A progress note, dated 8/23/25 at 11:59 PM, indicated Resident A's spouse had been present when the resident's skin tear had reopened.A progress note, dated 8/27/25 at 11:59 PM, indicated Resident A had reopened a skin tear on their arm. The skin tear…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. On the label it indicated to give 2 puff every day until 5/3/25. At 9:58 AM Resident 104 had an opened medication bottle of Antacid tablet 750 mg with no open date. At 10:01 AM Resident 43 had an opened bottle of Morphine sulfate 5 ML with a small syringe, inside a clear plastic cup. The syringe was facing downward in the cup at the bottom, it was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure freedom from intimate touching for 2 of 19 residents reviewed (Resident 53 and Resident 99).Findings include: Resident 53's record was reviewed on 08/26/2025 1:15 PM. Diagnoses included dementia, anxiety, and sexual dysfunction. A current annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident 53 had a Basic Interview for Mental Status (BIMS) score of 8 indicating cognitive impairment.A progress note dated 8/21/25 at 6:24 PM indicated staff reported inappropriate sexual behavior by Resident 53 with a male resident. The note indicated staff had intervened. No additional progress notes or assessments after 8/21/25 at 6:24 PM were documented from nursing or social services pertaining to sexual behavior.No further progress notes or assessments were available for review at the time of facility exit. A current care plan titled .impaired cognitive function . indicated Resident 53 had a problem of impaired thought…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure an occurrence of non-consensual intimate touching was reported for 1 of 19 residents reviewed (Resident 99). Resident 99's record was reviewed on 08/26/2025 12:52 PM. Diagnoses included dementia with behavioral disturbance and sexual dysfunction. A current annual Minimum Data Set (MDS) assessment, dated 7/26/25, indicated Resident 99 had a Basic Interview for Mental Status (BIMS) score of 4, indicating cognitive impairment. A progress note, dated 8/21/25 5:50 PM, indicated Resident 99 exhibited inappropriate sexual behavior in the dining room before the supper meal. The note indicated Resident 99 touched Resident 53 between her legs on the outside of her clothes. The note indicated staff intervened and the Resident 99 was assisted away from the situation. No notes including documentation of notification of family or Nurse Practitioner were available for review. In an interview, on 08/28/2025 9:38 AM, the Administrator indicated Resident 53 and Resident 99 had a history of sexual contact around the beginning of 2025.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure wound care was provided to promote healing and prevent infection for 1 of 3 residents reviewed (40).Findings include:During an observation, on 08/27/2025 10:16 AM, Registered Nurse (RN) 7 removed wound care supplies from a cart outside Resident 40's room. She carried a package of alginate wound preparation, an abdominal (ABD) pad, a package of kerlix (roll gauze used to wrap limbs), a pair of scissors, a bottle of wound cleanser and a barrier sheets into Resident 40's room. She held the items against her body as she placed a barrier sheet on the overbed table in Resident 40's room and then placed the supplies on top of the barrier prior to applying a gown and gloves. She placed another barrier sheet underneath Resident 40's right foot and removed her sock. She used the scissors to cut and remove kerlix wrapped around Resident 40's right heel. She placed the scissors back on the barrier on the overbed table. The scissors had not been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility the failed to ensure communication with the dialysis provider for 1 of 1 residents reviewed. (Resident 57)Findings Include:Resident 57's record was reviewed on 8/26/2025 at 1:25 PM. Diagnosis included end stage renal disease, dependence on renal dialysis, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, metabolic encephalopathy and anemia in chronic kidney disease. A review of physician orders, on 8/28/2025 at 9:10AM, indicated Resident 57 needed to leave the facility for dialysis at 4 AM on Monday, Wednesday and Friday and the facility is to complete pre- and post-dialysis assessments. On 8/28/2025 at 10:59 AM, in an interview, Registered Nurse 8 (RN), indicated she had not seen a dialysis book, however she was new. RN 8 indicated she asked Licensed Practical Nurse 9 (LPN) and they indicated there was no dialysis book.On 08/28/2025 at 1:45 PM, the Administrator provided a dialysis communication book for Resident 57. The dialysis book included a Nurse Responsibilities for Dialysis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure completion of physician ordered laboratory tests for 1 of 5 residents reviewed. (Resident 30)Findings Include:Resident 30's record was reviewed on 8/27/2025 at 9:52AM. Diagnoses included: Vitamin D Deficiency, fatty (change of) liver, other seizures and major depressive disorder single episode unspecified. Resident 30's record was reviewed on 8/28/2025 at 1:38PM. Orders included: Depakote Oral Tablet Delayed Release 250MG (Divalproex Sodium), Ammonia & Depakote Level every day shift every 2 month (s), Annual Vitamin D &TSH every day shift every 365 days(s) for April and Hepatic & Lipid panel every day shift every 6 month(s). On 08/28/2025 at 10:28 AM, in an interview, the Administrator, indicated the facility had identified an issue with the Medication Administration Record (MAR) not notifying staff labs needed to be drawn. On 8/28/2025 at 1:36PM, in an interview, the Administrator, indicated she was providing the labs she was able to locate. The Administrator indicated she was not able to find any additional lab…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the root cause of falls was assessed, care plan interventions were developed and implemented to prevent further falls from occurring for 1 of 3 residents reviewed for accidents (Resident B). Findings include: A report, dated 6/5/25, indicated Resident B had 2 falls, within a couple days, resulting in a fractured leg. Resident B's family member alleged the facility hadn't provided adequate supervision and care to prevent the falls and injury. On 6/23/25 at 11:41 A.M., Resident B's record was reviewed. Diagnoses included Alzheimer's dementia and post-hip fixation after a fall causing fracture. The resident was admitted to the facility for rehabilitation with a goal of discharging back to her daughter's home where she had lived. A nursing admission screen form, dated 5/8/25 at 10:26 a.m., indicated Resident B was alert and oriented to self and time; had short-term memory issues; used briefs for bladder and bowel incontinence; had unsteady gait, weakness, poor balance; and was to stand/pivot/sit using her left leg only.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was assessed and the physician notified timely following acute changes in condition, advance directives for transfer to a hospital were followed, and physician orders followed for 1 of 3 residents reviewed (Resident B). Findings include: A report, dated 5/21/25 at 12:41 p.m., indicated Resident B had been transferred to the hospital where she passed away. A family member alleged the resident hadn't been assessed and sent to the hospital timely, per the resident's advanced directives, when she required emergency care for a change in condition. The family member alleged the resident had been administered a higher dosage of medication than prescribed which she believed, led to the resident's demise. She alleged when family spoke with facility staff about the medication, the staff's explanations were inconsistent as was documentation of the administered medication in the resident's medical record. On 5/28/25 at 11:43 A.M., Resident B's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure dementia care and services was provided to 2 of 3 residents reviewed for dementia care (Resident J and Resident K). Findings include: On 3/10/25 at 10:30 A.M., the secured Memory Care Unit (MCU) was toured. Several residents were observed seated at tables in the dining room/activity area. Some were sleeping while others stared blankly ahead. There were no activities occurring. A television, mounted on the wall was not turned on and there was no music played. In one corner of the room, on shelves, were games and other activity equipment. The equipment was not being used by any residents in the area. One resident was observed standing near one of the tables, repetitively wiping the table while his table mate sat across from him looking on. A female resident, with a white/yellow substance on her teeth and lips, sat at another table fidgeting with her hair and clothing while another female resident, was propelling her wheelchair and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure a resident received appropriate oxygen therapy for 1 of 2 residents reviewed for respiratory care. (Resident 74). Findings include: During an observation on 9/26/22 at 11:18 AM, Resident 74 was in her wheelchair with oxygen at 3 liters per minute (LPM) on nasal cannula (tubing used to deliver oxygen through the nostrils) by her portable oxygen concentrator (a light, small and quiet device that allows you to receive supplemental oxygen). During an observation on 9/27/22 at 10:51 AM, Resident 74 was in her wheelchair with oxygen at 3 LPM via nasal cannula. During an observation on 9/28/22 at 9:57 AM, Resident 74 was in her wheelchair with oxygen at 3 LPM via nasal cannula. On 09/29/23 at 10:18 AM, Resident 74's record was reviewed. Diagnoses included chronic obstructive pulmonary disease (COPD), hypothyroidism, obesity, and a personal history of COVID-19. Resident 74's quarterly Minimum Data Set (MDS) assessment, dated 7/22/23, indicated the resident's Brief Interview for Mental Status (BIMS) score was 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.