Lutheran Home, the

Inspectors wroteBased on interview and record review, the facility failed to maintain a system to safeguard resident trust petty cash by commingling money from other sources with resident trust petty cash and by failing to reconcile the resident trust petty cash account. This had the potential to affect all residents whose funds were maintained by the facility. The facility census was 181. The facility did not provide a policy regarding the management, reconciliation, and safeguarding of resident trust petty cash. Observation of the resident petty cash box count and review of the petty cash log on 07/10/26 at 11:15 A.M., showed:- Administrative Assistant E counted $474.50 in resident trust petty cash. The petty cash log showed receipts totaling $435.38. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) assessments accurately reflected residents' clinical status for two (Residents #12 and #18) out of 35 sampled residents. The facility inaccurately coded Resident #12 as receiving hospice services when the resident was not enrolled in hospice and inaccurately coded Resident #18 as receiving insulin during the MDS look-back period when no insulin was administered. These inaccurate assessments had the potential to affect resident care planning, quality measures, and the accuracy of federally required resident assessment data. The facility census was 181. The facility did not provide a policy for MDS accuracy. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2025, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders by failing to administer a physician-ordered as needed (PRN) antihypertensive medication when the systolic blood pressure (SBP - top number. Normal range: 90-120) exceeded the ordered treatment parameter of greater than 160 millimeters of mercury (mmHg) for one resident (Resident #173) out of 35 sampled residents. The facility census was 181. Review of the facility policy titled, Medication Transcription, undated, showed:- PRN ordered medications are administered only as needed according to a designated time frame identified in the order;- The licensed nurse assesses the resident and makes the decision when to administer the PRN medication. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an individualized, person-centered care plan to address post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event) triggers and interventions for one (Resident #7) of three sampled residents reviewed for behavioral health. Although the resident had a diagnosis of PTSD, documented trauma history, and identified individualized triggers and care preferences, the facility failed to identify those triggers or interventions on the resident's care plan. As a result, staff lacked guidance to consistently provide trauma-informed care and reduce the risk of triggering the resident's PTSD symptoms. [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for one resident (Resident #76) out of 32 sampled residents and one resident (Resident #170) outside the sample. The facility's census was 163. The facility did not provide a policy. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual showed: - Section O0110K1, Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions; - Section J1400: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices when staff failed to perform hand hygiene during perineal care (peri care - cleaning the genital and anal area) and catheter (a tube that is inserted into the bladder, allowing urine to drain freely) care for one resident (Resident #67) out of 32 sampled residents and one resident (Resident #15) outside the sample. The facility also failed to wear proper Personal Protective Equipment (PPE) for Enhanced Barrier Precaution (EBP) during care for two residents (Resident #100 and #131) out of 32 sampled residents. The facility's census was 163. Review of the facility's policy, Handwashing/Hand Hygiene, undated, showed: - The facility recognizes that handwashing is the most effective measure for the prevention of infection and cross-contamination. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 168. Review of the facility's policy titled, Cleaning and Sanitation of Dining and Food Service Areas, dated 11/14/23, showed: - The dining service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule; - The Certified Dietary Manager (CDM)/dining service director/kitchen manager/designee will record all cleaning and sanitation tasks for the department; - All staff will be trained on the frequency of cleaning necessary; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 29 opportunities with two errors made, resulting in an error rate of 6.9% for two residents (Resident #49 and #105) out of six sampled residents. The facility's census was 168. Review of the Humalog/lispro (a rapid insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (Insulin in a pen-type device) instructions, revised, July 2023, showed: - Remove cap; - Attach needle; - Prime pen by turning dose selector to two units; - Hold pen with needle pointing up, press and hold button until it stops and the zero is seen in the dose window along with visible insulin at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the dumpsters were closed at all times and maintained to keep pest out and/or to keep the garbage contained in the dumpster. The facility census was 168. The facility did not provide a policy regarding the dumpsters. Observations on 02/06/24 at 10:30 A.M., and 02/06/24 at 3:01 P.M., of the outside 200 Hall kitchen showed a two-lid dumpster with both lids opened with visible trash bags and other miscellaneous items. Observations on 02/06/24 at 10:54 A.M., and 02/06/24 at 3:18 P.M., of the outside 300 Hall kitchen, showed a two-lid dumpster with both lids opened with visible trash bags and other miscellaneous items. Observation on 02/07/24 at 10:01 A.M., of the outside 300 Hall kitchen showed a two-lid dumpster with one lid opened with visible trash bags and several broken down cardboard boxes. [...]