Luther Oaks

Inspectors wroteBased on observation, interview, and record review, the facility repeatedly failed to maintain complete and accurate medical records for two of three (R1and R3) residents reviewed for falls on the sample list of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe transfer for one of three residents (R2) reviewed for falls on the sample list of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 16 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to store dishes in a sanitary manner, clean food preparation areas with appropriate chemicals, ensure staff's hair was secure to prevent food contamination, and ensure ice cream lids were in place to prevent cross contamination. These failures have the potential to affect all 16 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to have an infection control surveillance program in place and failed to prevent cross contamination when administering medications. These failures have the potential to affect all 16 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to protect the resident's right to be free from physical and verbal abuse by another resident. This failure affects three residents (R4, R16, R271) of three residents reviewed for abuse in a sample list of 24 residents.

Inspectors wroteBased on interview and record review the facility failed to complete a level two Pre-admission Screening and Resident Review (PASARR) after a mental health diagnosis was added to R6's electronic medical record. This failure effects one (R6) of five residents reviewed for PASARR in a sample list of 24 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and track behaviors before giving a diagnosis of Schizophrenia for the administration of antipsychotic medications for one (R6) of five residents reviewed for diagnosis without assessment in sample list of 24 residents.

Inspectors wroteBased on interview and record review the facility failed to provide an individual discharge plan for R18 who was discharged on 7/26/24 to Independent Living . R18 is one of one resident reviewed for discharge planning in sample of 24.

Inspectors wroteBased on observation, interview and record review the facility failed to provide shaving care for two residents (R12, R13) dependent on staff assistance of 16 residents reviewed for shaving care from a total sample list of 24 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide hygienic oxygen masks and tubing and failed to label and contain the oxygen masks and tubing for two (R13, R7) of two residents reviewed for respiratory care from a total sample list of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify behaviors and implement non-pharmacological interventions prior to the use of psychotropic medications for one (R6) of five residents reviewed for psychotropic medications on the sample list of 24 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to honor resident food preferences for one of one residents (R5) reviewed for food preferences in a sample list of 24 residents.

Inspectors wroteBased on interview and record review the facility failed to have an antibiotic stewardship program in place for two (R9, R12) of six residents reviewed for antibiotic stewardship on the total sample of 24 residents.

Inspectors wroteBased on interview and record review the facility failed to provide a safe transfer for one (R1) of three residents reviewed for falls on the sample list of five.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate supervision for a dependent resident to prevent a fall, thoroughly investigate a fall, implement post fall interventions, and report a fall timely to the physician and resident representative for three of four residents (R1, R2, R3) reviewed for falls on the sample list of 18. This failure resulted in R1 falling in the bathroom after being left unattended and sustaining a head laceration requiring two staples.

Inspectors wroteBased on interview and record review, the facility failed to notify physician and resident representative of a change in medical condition for one of four residents (R4) reviewed for notification of changes in condition on the sample list of four. Findings Include: R4's Treatment Encounter Notes by V12 PTA (Physical Therapy Assistant)/Therapy Director documents: 12/27/23 - R4 refused PT (Physical Therapy) this morning due to not feeling up to it but agreed to do it in the afternoon/evening. R4 reports feeling weak. R4 also reports moderate left leg pain during gait (knee to ankle on anterior aspect). R4 was observed to pick left foot up from ground and shake it out during gait. Increased assistance required for transfers. Nurse reports R4 was very weak and did not feel well yesterday. [...]

Inspectors wroteBased on interview and record review the facility failed to administer Pneumococcal Conjugate Vaccine (PCV) 13, PCV 15, PCV 20 and/or Pneumococcal Polysaccharide Vaccine (PPSV) 23 to four (R1, R3, R4, R8) residents out of five residents reviewed for vaccinations in a sample list of 16 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and label premade salads and gelatin in a manner to prevent contamination. This failure had the potential to affect all 18 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to transmit Discharge Minimum Data Set (MDS) assessments within 14 days of the completion date for two of two residents (R14, R19 ) reviewed for Discharge MDS assessments on the sample list of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the formation of a Stage II Pressure Ulcer caused by equipment, failed to assess a facility acquired Pressure Area and failed to prevent cross contamination during Pressure Ulcer dressing change for two (R16, R4) out of three residents reviewed for pressure ulcers in a sample list of 20 residents.