Lutheran Home for the Aged

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were three (3) medication errors out of 30 medication opportunities, resulting in a 10% medication error rate.

Inspectors wroteBased on interview and record review the facility failed to safely reposition a resident during care. This failure resulted in R1 falling from her bed and sustaining a right patella fracture. This applies to 1 of 4 residents (R1) reviewed for safety in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was safely transferred with a mechanical lift, resulting in the resident sustaining a fractured toe. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in the sample of 3. R1's BIMS-Brief Interview of Mental Status dated 07/16/25 shows, R1 is Cognitively Intact. On 07/16/2025 at 9:51AM, R1 was sitting in her wheelchair. R1 was wearing a surgical shoe on her right foot. R1's right great toe had a grey/black bruise. On 07/16/2025 at 9:51AM, R1 said, I have used a wheelchair for the past 8 years. I used to be able to use a slide board with two persons assist. Currently, I am a full body mechanical sling lift. I have a displaced fracture to my right toe. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was safely transferred using a mechanical sit to stand lift for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 being assisted to the ground and sustaining a proximal tibia and fibula fracture of her right leg.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely transport a resident in their wheelchair. This applies to 1 of 5 residents (R1) reviewed for safety in a sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate pain control for a resident with a history of cancer and compression fracture. This failure resulted in R1 experiencing increased pain from 4/21/2025 to 4/24/2025. This applies to 1 of 3 (R1) residents reviewed for pain in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure misappropriation of resident funds did not occur for 1 of 3 residents (R1) reviewed for misappropriation of resident funds in the sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to notify the police when a resident's credit card was missing and could not be located for 1 of 3 residents (R1) reviewed for misappropriation of residents' funds in the sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to communicate and effectively treat a resident's pain; and failed to verify and obtain a resident's ordered pain medication in a timely manner for 1 of 1 resident (R425) reviewed for pain in the sample of 35. These failures resulted in R425 experiencing continued pain and emotional anguish.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure insulin was refrigerated or dated and failed to ensure controlled medications were double locked for 2 residents in the sample (R8, R172) and 4 residents outside of the sample (R367, R375, R41, R179).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide feeding assistance in a dignified manner and failed to utilize a catheter dignity bag. This applies to 2 of 2 residents (R108, R425) reviewed for dignity in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to obtain a Level I Preadmission Screening and Resident Review (PASSAR) for a resident who admitted with a serious mental health diagnosis for 1 of 1 residents (R77) reviewed for PASSAR in a sample size of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living for a resident assessed to be dependent on staff for grooming and personal hygiene for 1 of 1 residents (R166) reviewed for activities of daily living in a sample size of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a wound vacuum was operational, failed to ensure physician orders were obtained, and failed to have care interventions in place for 1 of 3 residents (R371) reviewed for non-pressure wounds in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure preventative measures were in place, correct treatment orders were in place, and air mattress settings were for a resident's weight for 3 of 3 residents (R197, R280, & R466) reviewed for pressure in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to supervise a resident with difficulty swallowing while eating for 1 of 6 residents (R8) reviewed for safety in the sample of 35.

Inspectors wroteBased on observation, Interview, and Record Review the facility failed to ensure a resident's indwelling urinary catheter bag was not on the floor or stepped on for 1 of 1 residents (R291) reviewed for catheters in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enhanced barrier precautions were implemented for residents with surgical wounds (R371, R197) and failed to ensure personal protective equipment was worn during catheter care (R291) for 3 of 8 residents reviewed for infection control in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcers and failed to identify a pressure ulcer for 2 of 3 residents, R1 and R3, reviewed for pressure injuries in the sample of 3. These failures resulted in R1 developing a Stage 3 sacral pressure wound which later became an infected Stage 4 pressure ulcer and R3's pressure wound not receiving wound care treatment until it was an unstageable pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer two of two residents (R1, R3) reviewed for safe transfers in the sample of three. This failure contributed to R1 falling forward out of her wheel chair which required a transfer to a local hospital where R1 was diagnosed with a brain hemorrhage.

Inspectors wroteBased on interview and record review the facility failed to ensure slippery wet floors were dried prior to safely transferring a resident after showering. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to provide ordered chemotherapy drugs for one of three residents (R1) reviewed for medications in the sample of three.

Inspectors wroteBased on interview and record review the facility failed to assess a resident prior to being moved off the floor for 1 of 1 resident (R1) reviewed for safety in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure continuity of medications for a resident being discharged to home. This applies to 1 of 3 residents (R1) reviewed for discharge planning in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was transferred safely for one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in R1 obtaining a right surgical neck fracture (Right shoulder area). This past non-compliance occurred from February 19, 2024-February 23, 2024.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from sexual abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was given privacy for a physician visit which effects 5 of 35 residents (R40, R67, R70, R160, R209) reviewed for privacy in a sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the facility's water management policy after a resident room tested positive for Legionella. The facility failed to implement their enhanced barrier precautions policy which applies to 25 residents (R98, R15, R107, R177, R194, R4, R31, R20, R122, R18, R190, R117, R202, R148, R43, R116, R57, R204, R74, R210, R163, R175, R27, R3, R232) reviewed for infection control in a sample of 35.

Inspectors wroteBased on interview and record review the facility failed to verify a resident's code status was clarified. This applies to 2 of 35 (R243 & R173) in the sample of 35 reviewed for advance directives. On 12/19/2023 at 1:54PM, V17 Social Services said nursing staff addresses code status upon admission if they provide documentation. V17 said social services follows up on code status to complete the POLST forms. V17 said they did not follow up on R243's and R173's advance directives. V17 said she was unaware she couldn't just write FC on the POLST without a signature. V17 said she now knows its not valid without a signature. R243's Order Summary Report active as of 12/19/2023 shows an active order for Full Code ordered on 11/10/2023. R243's Order Summary Report shows an order for DNR/DNI needs updated POLST form completed ordered on 12/2/2023. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident had a PASARR (Preadmission Screening and Resident Review) completed prior to admission for 1 of 8 residents (R189) reviewed for PASARR's in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure pressure injury treatments and pressure relieving interventions were in place for 2 of 8 residents (R19, R463) reviewed for pressure injuries in the sample of 35.

Inspectors wroteBased on observation, interview and record review facility staff failed to maintain a resident's indwelling urinary catheter bag below the level of the resident's bladder and off the floor for 1 of 5 residents (R19) reviewed for indwelling urinary catheters in the sample of 35.

Inspectors wroteBased on interview and record review the facility failed to identify a significant weight loss. This applies to 1 of 10 (R243) in the sample of 35 reviewed for weight loss. On 12/19/2023 at 12:05PM, V19 Dietary Technician and V20 Registered Dietician were interviewed together regarding R243. V19 said [R243] should have triggered for weight loss on 12/4/2023. V19 and V20 said they were unaware of the weight loss. V20 said a weight loss of >5% in 30 days is considered a significant weight loss and should be followed up on. R243's Order Summary Report dated 12/19/2023 shows an active order for weekly weights started on 11/12/2023. R243's Weights and Vitals Summary dated 12/21/2023 shows a weight of 171.6 lbs on 11/10/2023 and a weight of 160.2 lbs on 12/4/2023 a weight change of 6.64% within 30 days. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received physical therapy services as requested for 1 of 8 residents (R232) reviewed for therapy in the sample of 35.

Inspectors wroteBased on interview and record review the facility failed to treat a resident in a dignified manner for 1 of 3 residents (R1) reviewed for residents rights in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's representative of a skin alteration for 1 of 3 residents (R1) reviewed for notification in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a gait belt was used to safely transfer a resident. This failure contributed to R1 falling and sustaining a right femur fracture requiring hospitalization and surgical intervention. This applies to 1 of 5 residents (R1) reviewed for safety/supervision in the sample of 5.