Carroll Lutheran Village

Inspectors wroteBased on observations of the facility's kitchen, review of kitchen records, and interview of dietary staff, it was determined that the facility failed to store food items to maintain the integrity of the specific item, and prevent ice from building up on the floor in the walk-in freezer. These deficient practices have the potential to affect all residents served food out of the facility's kitchen identified during the recertification survey.

Inspectors wroteBased on medical record review, and staff interviews, it was determined that the facility failed to review and revise care plans by Interdisciplinary team (IDT) members, when quarterly, annual, and significant change assessments were completed. This was evident for one resident (#44) of the 29 Residents reviewed for the care plan participation during the recertification survey.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility staff failed to follow physician orders and label oxygen tubing and humidifier bottle when changed. This was evident for 1 (Resident #20) of 29 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure that a resident was given pain medication consistent with professional standards of practice. This was evident for 1 (Resident #20) of 29 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents. This was evident for 1 (Resident #12) of 29 residents observed during the recertification/complaint survey.

Inspectors wroteBased on a review of the medical record and staff interview, it was determined that the facility failed to ensure accurate documentation of staff communication with the Resident. This was evident for 1 (Resident # 64) out of 29 Residents reviewed for accurate medical records during the recertification survey.

Inspectors wroteBased on medical record and employee file review and interviews, it was determined that the facility failed to have an effective system in place to ensure that newly hired geriatric nursing assistants (GNA) demonstrated skills competency prior to being allowed to independently care for residents. This was found to be evident for two out of the two recently hired GNAs selected for review (GNA #28 and #32) and had the potential to affect all of the residents.

Inspectors wroteBased on observations and interviews of the facility's kitchen, dietary staff and nursing staff, it was determined that 1) the facility failed to ensure food was stored and dated properly, 2) the facility failed to ensure food was stored and maintained in a safe manner to reduce the risk of foodborne illness, and 3) the facility failed to ensure sanitary practices were followed in accordance with professional standards for food service safety. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on review of previous annual surveys and deficient practices identified during this survey, it was determined that the facility failed to have an effective Quality Assurance program as evidenced by the identification of deficiencies related to food safety requirements for the past 3 annual surveys and again during the current survey; and the identification of deficiencies related to Infection Prevention and Control on three surveys since the start of the COVID pandemic. The failure to identify and develop appropriate plans of corrections to correct quality deficiencies places all residents at risk.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 6 of 36 residents (#20, #11, #53, #60, #120, #4) reviewed during the annual survey.

Inspectors wroteBased on observation, medical record review and interview, it was determined that the facility staff failed to maintain a medical record in the most accurate form. This was evident for 4 of 22 residents(Resident #13, #11, #120, #121) with care area investigations completed during the survey.

Inspectors wroteBased on observation, staff interview and record review, it was determined the facility failed to ensure an effective infection prevention and control program by failing to ensure that staff performed hand hygeine when indicated, failed to utilize personal protective equipment (PPE) in a manner that met minimum standards and minimize risk for infectious spread, and failed to ensure proper handling of a resident's Foley Catheter urine bag. This was found to be evident during observations of 9 residents (Resident #37, #54, #30, #53, #41, #20, #25, #60 and #61) but this noncompliant practice within the facility's infection prevention and control program left all residents, staff, and visitors at increased risk for infection during an active COVID-19 outbreak in the facility.

Inspectors wroteBased on observation and medical record review, it was determined facility staff that failed to treat a resident with dignity as evidence by standing to feed the resident while in a dining room with other residents. This was evident for 1 of 16 residents (Resident #13) observed for dining in the Good [NAME] Way Unit.

Inspectors wrote3. Psychotropic medications are used to treat mental health disorders. There are five main types of psychotropic medications, and each type has its own specific uses, benefits, and side effects. The five main types are anti-anxiety agents, antidepressants, antipsychotics, mood stabilizers, and stimulants. On 09/01/21 at 08:32 AM review of Resident #17's medical record revealed the resident was diagnosed with Major Depressive Disorder and Anxiety Disorder. On 09/01/21 at 08:40 AM, a record review of Resident #17's Medication Administration Record (MAR) revealed the resident had an order for Mirtazapine tablet 15 mg related to Major Depression Disorder and Duloextine HCL Capsule Delayed Release Sprinkle 30 mg related to Major Depression Disorder. Mirtazapine (Remeron) is an antidepressant medicine. [...]

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for a Resident (#13) with a history of skin tears. This was evident for 1 of 2 residents (Resident #13) reviewed for skin conditions during the annual survey.

Inspectors wroteBased on observation, medical record review, and interviews, it was determined that the facility staff failed to meet professional standards by 1) documenting that a treatment of an application of geri-sleeves was applied to a resident's arms every day when the geri-sleeves were observed not on the resident and 2) documenting that a treatment of TED stockings were worn by a resident when they were observed not on the resident. This was evident for 1 of 2 residents (Resident #13) reviewed for skin conditions and 1of 5 residents (Resident #11) reviewed for unnecessary medications during the annual survey.

Inspectors wroteBased on observation, record review and staff interview, it was determined facility staff failed to provide care and treatment in accordance with the resident's physician's orders as evidenced by the facility staff documentation that a treatment was performed when it was observed not performed, and failed to ensure physical and occupational therapy screening was completed as ordered by the physician. This was found to be evident for 3 out of 22 residents (Resident #13, #11 and #64) with care area investigations completed during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to prevent a resident from falling out of bed while receiving care. This was found to be evident for one out of eight residents reviewed for accidents (Resident #66) during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to monitor the blood pressure and heart rate prior to administering a blood pressure medication per physician's orders. This was evident for 1 of 5 residents (Resident #53) reviewed for unnecessary medications during the annual survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure a resident receiving antipsychotic medication had an attempted gradual dose reduction (GDR). This was evident for 1 out 5 residents (Resident #11) reviewed for unnecessary medications during the annual survey.

Inspectors wroteBased on observation and staff interview, it was determined that facility staff failed to keep medication carts locked when unattended. This was evident on 1 of 2 nursing units observed during the annual survey.

Inspectors wroteBased on observation, it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of insects. This was evident for the ground floor and the kitchen.

Inspectors wroteBased on observations of the facility's food service operations and staff interviews, it was determined that the facility failed to assure proper sanitation of dish and cookware and failed to utilize appropriate hair restraints to keep hair from contacting food and food contact surfaces. Concerns were identified in main kitchen and the auxiliary kitchen in the health care center.

Inspectors wroteBased on observation and interviews with staff and residents, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment for residents as evidenced by 1. unclean resident wheelchairs, 2. damaged or missing resident overbed tables, and 3. other damage noted in resident rooms. This was true for 2 (Residents #6 and #27) of 7 Residents and 2 (Rooms #415-2 and #413) of 24 resident rooms observed. The evidence includes: 1. During an observation of resident wheelchairs that took place on 9/24/2018 at 10:05 AM, it was noted that Resident #6's wheelchair had a layer of dust and sticky dirt on the crossbars and lower parts of the chair. The resident stated dirty when the surveyor pointed to these parts. It was also noted that Resident #27's wheelchair had dirt on the lower chassis. [...]

Inspectors wrote3. Review of Resident #88's medical record on 9/25/18 revealed that the resident was discharged to a hospital on 6/22/2018. A late entry note was written on 6/23/18 indicating that resident #88 was experiencing chest pain and was sent to the hospital emergency room for evaluation. The note contained documentation that a doctor was notified and the resident's wife. The note did not contain any information that resident #88 was informed of the transfer to hospital, and the resident's response to the transfer. An interview was conducted with a staff educator (staff #17) at 1:33 PM on 9/25/18. The requirement of this regulation was reviewed with staff #17. [...]

Inspectors wroteBased on observation, staff interview and facility documentation review, it was determined the facility staff failed to 1) keep medication storage areas clean, 2) failed to label a medication when opened and 3) failed to lock a medication cart when unattended. This was evident for 3 of 5 medication carts observed.

Inspectors wroteBased on observations, medical record review and interviews with facility staff, it was determined the facility failed to ensure that a resident's call bell was within reach at all times. This was evident for 2 (#65, #72) of 30 residents observed in the 200 hall.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to notify the physician of a significant weight gain. This was evident for 1 (#28) of 5 residents reviewed for nutrition.

Inspectors wroteBased on a random sample of Medicare beneficiaries who were discharged from skilled therapy and nursing services within the past six months, it was determined that 1 (#43) of 3 Medicare beneficiaries reviewed did not receive written notice of Medicare Provider Non-Coverage.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan with measurable goals. This was evident for 1 (#87) of 1 resident reviewed for hydration and 1 (#72) of 2 residents reviewed for accommodation of needs. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on review of resident records and interview with facility staff, it was determined that the facility failed to include parameters for two as-needed pain medication orders. This was true for 1 of 5 residents (Resident #16) reviewed for unnecessary medications. The evidence includes: During a review of Resident #16's medical record that took place on 9/24/2018 at 9:45 AM, the following orders were found: Acetaminophen caplet 500mg: administer 2 caplets (1gram) by mouth every eight hours as needed for pain, and Tramadol tablet 50mg: Take 3 half tabs (75mg) by mouth every eight hours as needed for pain. Acetaminophen and tramadol are both pain relievers. Acetaminophen is available over-the-counter and is used more often as a first line pain medication than tramadol, which is stronger and requires a prescription. [...]

Inspectors wroteBased on medical record review and interview with staff, it was determined that the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs. This was evident for 1 (#11) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 6 (#5, #87, #88, #3, #65, #188) of 6 residents reviewed for transfers to an acute care facility.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 6 (#5, #87, #88, #3, #65, #188) of 6 residents reviewed for transfers to an acute care facility.