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Deficiency Records for Lewis Memorial Christian Vlg
A list of the most recent deficiencies for Lewis Memorial Christian Vlg. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Lewis Memorial Christian Vlg. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-19 | 2024-08-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-19 | 2024-08-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-08-19 | 2024-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-19 | 2024-08-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-08-19 | 2024-08-30 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-07-11 | 2024-07-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-11 | 2024-07-24 | Y |
| Post nurse staffing information every day. | Health | 2024-05-30 | 2024-06-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-30 | 2024-06-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-30 | 2024-06-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-30 | 2024-06-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-08 | 2024-04-16 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-04-08 | 2024-04-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-20 | 2024-04-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-20 | 2024-04-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-20 | 2024-04-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-20 | 2024-04-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-03-20 | 2024-04-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-11 | 2023-12-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-11 | 2023-12-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-24 | 2023-12-18 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-11-16 | 2023-12-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-16 | 2023-12-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-16 | 2023-12-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-16 | 2023-12-01 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-08 | 2023-11-22 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-24 | 2023-11-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-24 | 2023-11-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-24 | 2023-11-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-24 | 2023-11-06 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-15 | 2023-09-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-23 | 2023-09-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-30 | 2023-09-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-30 | 2023-09-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-30 | 2023-09-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-30 | 2023-09-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-23 | 2023-07-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-23 | 2023-07-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-23 | 2023-07-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-21 | 2023-07-27 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-05 | 2023-07-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-07-05 | 2023-07-20 | N |
| Develop a communication plan. | Fire Safety | 2023-07-05 | 2023-07-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-07-05 | 2023-07-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-05 | 2023-07-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-07-05 | 2023-07-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-05 | 2023-07-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-05 | 2023-07-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-05 | 2023-07-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-05 | 2023-07-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-05 | 2023-07-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-07-05 | 2023-07-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-05 | 2023-07-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-05 | 2023-07-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-05 | 2023-07-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-23 | 2023-03-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-09 | 2022-11-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-13 | 2022-11-02 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-06-15 | 2022-06-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-15 | 2022-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-15 | 2022-06-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-15 | 2022-06-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-26 | 2022-06-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-17 | 2022-03-01 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-27 | 2021-10-23 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-08-27 | 2021-10-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-08-27 | 2021-10-12 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-08-27 | 2021-10-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-08-27 | 2021-10-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-27 | 2021-10-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-08-27 | 2021-09-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-08-27 | 2021-09-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-27 | 2021-09-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-27 | 2021-09-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-26 | 2021-09-24 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-08-26 | 2021-09-24 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-08-26 | 2021-09-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-26 | 2021-09-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-26 | 2021-09-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-26 | 2021-09-24 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-08-27 | 2021-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-27 | 2021-09-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-08-27 | 2021-09-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-27 | 2021-09-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-27 | 2021-09-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-08-27 | 2021-09-14 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-08-27 | 2021-09-14 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-08-27 | 2021-09-14 | N |
| Establish methods for sharing information. | Fire Safety | 2021-08-27 | 2021-09-14 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-08-27 | 2021-09-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-08-27 | 2021-09-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-08-27 | 2021-09-14 | N |
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