Luther Haven

Inspectors wroteBased on interview and document review, the facility failed to ensure resident status was accurately identified in the Minimum Data Set (MDS) assessment for 2 of 15 sampled residents (R8 and R29).

Inspectors wroteBased on observation, interview, and document the facility failed to have a process for monitoring personal refrigerators located in 1 of 15 sampled resident's (R23) room to ensure temps were monitored, food was not expired, and the refrigerator maintained to prevent potential food born illness.

Inspectors wroteBased on interview and document review, the facility did not assess or analyze trends of falls to determine causal factors or root cause and implement interventions to prevent or reduce the risk of falls with major injury for 1 of 3 residents (R1) reviewed who had falls. This resulted in actual harm when R1 suffered spinal compression fracture at T12 (thoracic spine last vertebrae), L1 and L2 (lumbar spine between the top two vertebrae) and a rib fracture as a result of two unsupervised falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate transmission based precautions used for 1 of 1 resident (R4) with diagnosis of Respiratory Syncytial Virus (RSV).

Inspectors wroteBased on observation, interview, and document review the facility failed to complete a timely comprehensive elopement risk assessment that addressed window type as a possible exit for mobile residents who were at risk for elopement for 1 of 3 residents (R1) who had a history of exit seeking. This resulted in immediate jeopardy (IJ) when R1 eloped from a window in her room and was found ½ mile from the facility approximately an hour later by the police and family member. The immediate jeopardy began on 12/28/24, when R1 eloped from the facility by exiting through the window in her room and was found an hour later 1/2 mile from the facility. The immediate jeopardy was identified on 1/9/25, and the assistant administrator was notified on 1/9/25, at 4:40 p.m. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to appropriately assess and/or follow the care plan and ensure safe transfers were performed for 3 of 3 residents (R11, R16, and R37) while using sit-to-stand mechanical lifts (EZ stand) (requires a resident to be partial weight-bearing) to prevent or mitigate falls or risk thereof. This resulted in an immediate jeopardy (IJ) for both R11 and R16 who fell from and EZ-stand and required hospital evaluation and treatment). Both events had the potential for serious harm, injury, impairment, or death. The IJ began on 8/29/24, when nurse aide (NA)-A failed to follow R11's care plan and ensure 2 staff transferred R11 while using an EZ-Stand. R11 let go of the bars on the EZ -Stand and fell backwards out of the sling, resulting in a laceration to the back of her head. [...]

Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 1 grievance policy and procedures were followed. The facility failed to post the grievance policy prominently and throughout the facility and provide forms to submit a grievance anonymously if desired. In addition, the facility also failed to document all grievances, the action taken to resolve grievances and the summary of the resolution to each grievance. This had the ability to affect all 54 residents.

Inspectors wroteBased on interview and record review, facility failed to ensure 8 of 8 nursing assistants ((NA)-A, NA-B, NA-F, NA-G, NA-H, NA-I, NA-J, and NA-K) 4 of 4 registered nurses (RN)-D, RN-E, RN-F and the infection preventionist (IP)), and 1 of 1 licensed practical nurse (LPN)-F were deemed competent on the operatioon of mechanical lifts and following care plans and care sheets, upon hire, yearly thereafter, or as needed when identified concerns with competence were noted. This had the potential to affect all 54 residents who had/may use mechanical lifts, and had care plans and care sheets.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff were not co-mingling personal food and effects with resident food. This had the potential to affect all 54 residents who ate food prepared from the kitchen.

Inspectors wroteBased on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed.

Inspectors wroteBased on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 54 residents.

Inspectors wroteBased on interview and document review the facility failed to ensure call lights were answered timely for 4 of 4 residents (R9, R29, R39, and R48) reviewed for activities of daily living (ADL's).

Inspectors wroteBased on observation and interview the facility failed to follow their policy and ensure discontinued medications for 5 of 5 residents (R12, R16, R52, R55, R108) were removed timely and not co-mingled with other current medication supply located in the East and [NAME] double locked narcotic medication drawer within the medication cart.

Inspectors wroteBased on interview and document review, the facility failed to ensure a fall with injury and potential neglect was reported to the State Agency (SA) for 1 of 3 residents (R11) reviewed for falls.

Inspectors wroteBased on interview and document review, the facility failed to complete an accurate and thorough investigation of falls to determine the root cause, if the care plan was followed, and if the fall was reportable to the State Agency (SA) for 1 of 3 residents (R11) reviewed for falls.

Inspectors wroteBased on interview and document review the facility failed to implement the reporting and investigation of injury of unknown origin according to their abuse policy for 1 of 3 residents (R1) reviewed for abuse. In addition, the facility failed to ensure the abuse policy identified reporting requirements to the State Agency (SA) according to the regulation.

Inspectors wroteBased on interview and document review the facility failed to report allegations of physical abuse (bruising of unknown origin) timely to the State Agency (SA) for 1 of 3 residents (R1)) reviewed for allegations of abuse.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure: 1) Staff appropriately stored and destroy both routine medication and controlled narcotic medication. This had the potential to affect all 64 residents in the facility. 2) There was a method or system in place for easy reconciliation and storage for controlled narcotic medication that had been received from pharmacy but was not yet in use to promote early detection of potential diversion. 3) Discontinued medication was not stored with in-use medication in 1 of 3 medication carts. 4) Staff were not taping unused medication back into 1 of 1 blister pack and appropriately discarded that medication. 5) 1 of 1 E-kit was appropriately secured and reconciled to prevent potential diversion. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure individual scoops were used during 1 of 1 meal service for eat food item on the steam table, and 1 of 1 kitchenette was maintained in a sanitary manner by kitchen staff. In addition, the facility failed to ensure 1 of 1 deep freezer located in the dining room, accessible to residents and visitors, was secured to prevent unauthorized access. This had the potential to affect all 64 residents in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 64 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop a comprehensive care plan for 8 of 16 sampled residents (R3, R15, R17, R49, R56, R58, R59, and R115) related to medication and target behaviors, smoking.

Inspectors wroteBased on observation, interview, and document review, the facility failed to use appropriate infection control technique during 1 of 1 dressing change for R56, and failed to ensure 1 of 1 Central Supply Room (CSR) which houses sterile and clean supplies, was not used as a catch all room including a staff breakroom or staff food storage room. In addition, the facility failed to ensure 1 of 1 mediation room was maintained in a sanitary manner.

Inspectors wroteBased on observation, interview, and document review, the facility failed to appropriately assess 1 of 1 resident (R56) for potential causes of thier left heel pressure ulcer and identify interventions to prevent worsening and/or acquiring new onset pressure ulcers.

Inspectors wroteBased on interview and document review the facility failed to ensure pharmacy consultant recommendations were followed up on in a timely manner for 2 of 2 resident (R31, R4) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review the facility failed to ensure clinical rationales for extended use of an as needed (PRN) antianxiety medication (lorazepam) beyond 14 days for 2 of 2 residents (R3 and R4).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications were administered according to professional standards of practice for 2 of 25 medication administrations, resulting in an 8% medication error rate.

Inspectors wroteBased on observation, interview and document review, the facility failed to have an integrated care plan to coordinate services between the facility and the hospice agency to ensure those services were being provided for 2 of 2 resident (R3, R45) reviewed for hospice care.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 residents (R31, R58, R114) were appropriately vaccinated against pneumonia upon admission. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all pets brought into 1 of 1 facility were overseen by a veterinarian and vaccinated. This had the potential to affect all 64 residents.