Inspection Reports for Lutheran Life Villages

This visit was for the Investigation of Complaint IN00461610.

No deficiencies related to the allegations are cited. Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00461610.

Complaint IN00461610 - No deficiencies related to the allegations are cited.

A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/16/25 was conducted by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).

At this PSR survey, Lutheran Life Villages was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.

An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.

The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included two exit doors that were magnetically locked and only accessible by staff key fobs, restricting egress, and incomplete documentation of electrical equipment testing for leakage current and touch current.

The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.

Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.

This visit was for a Recertification and State Licensure Survey conducted on March 13, 14, 17, 18 and 19, 2025.

The facility was found deficient in three areas: failure to follow physician orders for lab monitoring for one resident, failure to properly monitor and maintain a vascular access device for one resident, and failure to follow pharmacy recommendations for medication discontinuation for one resident. Corrective actions and monitoring plans were implemented for each deficiency.

This visit was conducted for the investigation of Complaint IN00443413.

No deficiencies related to the allegations in Complaint IN00443413 were cited. The facility was found to be in compliance with relevant regulations.

Complaint IN00443413 was investigated and found to have no deficiencies related to the allegations.

This visit was for the investigation of complaints IN00432549 and IN00432620.

No deficiencies related to the allegations were cited for either complaint. Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of the complaints.

Complaint IN00432549 - No deficiencies related to the allegations are cited. Complaint IN00432620 - No deficiencies related to the allegations are cited.

An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.

The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is fully sprinklered with a fire alarm system and smoke detection in required areas.

Paper compliance review to the Annual Recertification and State Licensure survey was conducted.

Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.

This visit was for a Recertification and State Licensure Survey conducted over multiple days in February 2024.

The facility was found deficient in monitoring an implanted intrathecal morphine pump for one resident, providing pressure ulcer care according to physician orders for another resident, and ensuring oxygen therapy was properly addressed in care plans and tubing was contained when not in use for a third resident. Plans of correction and staff training were implemented for each deficiency.

This visit was conducted for the investigation of complaint IN00422399.

No deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.

Complaint IN00422399 was investigated and found to have no deficiencies related to the allegations.

This visit was conducted for the investigation of Complaints IN00416400 and IN00417179 and included a COVID-19 Focused Infection Control Survey.

No deficiencies related to the allegations in Complaints IN00416400 and IN00417179 were cited. The facility was found to be in compliance with relevant regulations including 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.

Complaints IN00416400 and IN00417179 were investigated and no deficiencies related to the allegations were cited.

This visit was conducted for the investigation of Complaint IN00413712.

No deficiencies related to the allegations in Complaint IN00413712 were cited. The facility was found to be in compliance with applicable regulations.

Investigation of Complaint IN00413712 found no deficiencies related to the allegations; facility was in compliance.

This visit was for the Investigation of Complaint IN00412807.

No deficiencies related to the allegations are cited. Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00412807.

Investigation of Complaint IN00412807 with no deficiencies cited related to the allegations.

This visit was conducted for the investigation of Complaint IN00409062.

No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.

Complaint IN00409062 was investigated and found to have no deficiencies related to the allegations.

The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey completed on April 14, 2023.

Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.

An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.

The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is a fully sprinklered one-story building with a fire alarm system and smoke detection in required areas.

This visit was for a Recertification and State Licensure Survey conducted from April 10 to April 13, 2023.

The facility failed to implement intervention strategies for agitation and refusal of care for one resident (Resident 74) with behavioral issues. The resident exhibited multiple behaviors including hitting staff, refusal of care, and agitation, which were not addressed in the care plan or with psychiatric evaluation. The facility subsequently updated care plans, provided staff training, and implemented audits to ensure compliance.

This visit was conducted for the investigation of Complaint IN00402855.

The complaint IN00402855 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.

Complaint IN00402855 was substantiated, but no deficiencies related to the allegations were cited.

This visit was conducted for the investigation of complaints IN00393346 and IN00395272 at Lutheran Life Villages.

Complaint IN00393346 was unsubstantiated due to lack of evidence. Complaint IN00395272 was substantiated with federal/state deficiencies cited related to grievances. The facility failed to ensure grievances were thoroughly investigated, documented, and appropriate corrective actions were taken for one resident (Resident H).

Complaint IN00393346 was unsubstantiated due to lack of evidence. Complaint IN00395272 was substantiated. The complaint involved allegations that staff yelled at Resident H, threw her things, and said her room was messy. Observations confirmed Resident H's room was messy with a foul odor and soiled items. Grievance forms lacked documentation of investigation and resolution. Staff were unable to provide evidence of abuse determination. Facility policy on grievances was reviewed and corrective actions including training and audits were implemented.

Paper compliance review to the Investigation of Complaint IN00395272 completed on December 2, 2022.

Lutheran Life Villages was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.

Investigation of Complaint IN00395272; paper compliance review found facility in compliance.

This visit was conducted for the investigation of Complaint IN00389398.

The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.

Complaint IN00389398 was substantiated but no deficiencies related to the allegations were cited.