Good Shepherd Lutheran Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was displayed for residents, visitors, and staff to review. This had the potential to affect all residents currently residing in the facility, as well as all staff and visitors.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a self-administration of medication (SAM) assessment was completed and a provider order obtained to self-administer medications for 2 of 2 residents (R2, R69) reviewed for medication administration.

Inspectors wroteBased on observation and interview, the facility failed to promote independence for 1 of 1 resident (R 72) reviewed for self determination.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 2 of 6 resident reviewed for bedrails.

Inspectors wroteBased on record review, and interview, the facility failed to update the provider of a weight change per physician order for 1 of 5 residents (R8) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident receive adequate supervision and assistance for 1 of 1 resident (R5) when transferred with and EZ stand lift.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and attempt alternatives prior to use of bed rails for 2 of 6 residents (R55, R16 ) reviewed for bed rails.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to transcribe orders according to standards of practice for medication management for 1 of 5 (R150) residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were labeled with an opened-on date as well as an expiration date for 1 of 4 medication carts (500 wing cart) reviewed for medication storage and labeling.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all required data were included on the nurse staffing information posted daily. This had the potential to affect all 114 residents residing in the facility and their visitors who may wish to view the information.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement Program (QAPI) committee effectively sustained ongoing compliance related to repeat citations from past surveys regarding drug storage. This had the potential to affect all 114 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators and freezers were labeled, dated and discarded properly. In addition, the facility failed to maintain the ice machines in a sanitary manner to prevent potential food-borne illness. This deficient practice had the potential to affect all 116 residents who received food, beverages, and ice from the refrigerators, kitchen and ice machine.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 3 resident s (R5) who were observed to self administer a nebulizer and had not been assessed as safe to self administer medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow standards of practice related to medication administration of an inhalation medication for 1 of 3 residents (R5) observed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 4 residents (R12) with a current pressure ulcer and at risk for further development of pressure ulcers.

Inspectors wroteBased on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 7 medication carts.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 3 of 3 residents (R 5, R16, and R13) who resided on the North shore unit, reviewed for food. This deficient practice had the potential to affect all 21 residents residing on this unit.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure proper personal protective equipment (PPE) was used when providing cares for 1 of 1 residents (R80) reviewed for enhanced barrier precautions (EBP).

Inspectors wroteBased on interview and document review the facility failed to maintain records of a thorough investigation for 4 of 4 residents (R29, R318, R319, R50) related to facility reported events.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure post-dialysis assessment and monitoring was completed for 2 of 2 residents (R48, R108) reviewed for dialysis.

Inspectors wroteBased on interview and document review, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 2 of 5 residents (R42, R49), reviewed for hospitalization. This had the potential to affect all residents transferred to hospital.

Inspectors wroteBased on interview and document review, the facility failed to develop and implement a comprehensive person-centered care plan that addressed resident dialysis care for 2 of 2 residents (R48, R108) reviewed for dialysis.

Inspectors wroteBased on observation, interview and document review, the facility failed to provided bathing for 1 of 2 residents (R34) reviewed for dependent cares.

Inspectors wroteBased on observation and interview, the facility failed to maintain safe storage of medications when medication carts were left unlocked and unattended in 2 of 6 facility medication carts.