Lutheran Home

Inspectors wrote3.) On 2/11/25, the nurses note indicates R54 was experiencing a change in condition and was sent to the hospital. The nurses note on 2/11/25 indicates R54 was being admitted to the facility due to influenza and needing dialysis. On 6/9/25 at 3:10 p.m., during the daily exit meeting with NHA(Nursing Home Administrator)-A and DON (Director of Nursing)-B, Surveyor asked for a copy of the transfer and bedhold notice given to R54 for the 2/11/25 hospitalization. On 6/10/25 Surveyor received the transfer and bedhold notice dated 2/12/25 for R54. The transfer and bedhold notice does not include email address for state agency and facility and does not include information regarding the Ombudsman and how to contact the ombudsman. On 6/10/25 at 10:45 a.m. Surveyor interviewed NHA-A. NHA-A stated she understood the concern and had no additional information. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure each resident receives, and the facility provides food prepared by methods that conserve nutritional value, flavor, and appearance. This deficient practice had the potential to affect 8 residents receiving a puree diet. The recipe for preparing pureed diet was not followed to ensure puree food is prepared by methods that conserve nutritional value, flavor and appearance.

Inspectors wroteBased on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 3 resident unit refrigerators in the facility. This deficient practice had the potential to affect 46 residents residing on the affected unit. Residents' food stored in the refrigerator was not labeled and/or dated. The refrigerator temperature was not within the recommended temperature for safe food storage.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for 4 (R87, R12, R77 and R528) of 26 residents reviewed for Infection Control practices. * Surveyor observed Wound Medical Doctor (MD)-O, Nurse Manager-J, and Wound tech-P perform wound care for R87 without wearing proper Personal Protective Equipment (PPE). *Surveyor observed Certified Nursing Assistant (CNA)-K provide bowel incontinence care for R87 and did not change gloves and wash hands prior to performing peri care/catheter care. *Surveyor observed Advanced Practice Nurse Practitioner (APNP)- Q assess R87's right lower leg wound without proper PPE. [...]

Inspectors wroteBased on interview and record review the facility did not provide a comprehensive care plan for 1 (R96) of 5 residents reviewed for bowel and bladder incontinence. R96 is incontinent of bowel and bladder and did not have a comprehensive care plan for incontinence.

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R77, R87) of 26 residents needing assistance with Activities of Daily Living (ADL) cares, received the necessary services for cares. *R77 did not receive nail care per care plan, policy and resident's preference. *R87 did not receive scheduled shower per care plan and resident's preference.

Inspectors wroteBased on record review, interview and observation, the facility did not ensure residents with pressure injuries received the necessary treatment and services, consistent with professional standards of practice, to promote hearling, prevent infection and prevent new ulcers from developing for 2 (R112 and R20) of 7 residents reviewed with pressure injuries. * R112 was transferred to the hospital with a pressure injury. Upon readmission, R112's pressure injury was not comprehensively assessed until 3 days later. R112 did not have a comprehensive plan of care related to a comprehensive assessment. *R20 developed a pressure injury in the facility that was not comprehensively assessed. The facility's policy and procedure titled Skin Care Program and dated 6/17/2019, documents: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 2 (R59 and R96) of 5 residents reviewed were provided pain management services consistent with professional standards of practice, including completing comprehensive assessment, developing a comprehensive person-centered care plan and evaluating the resident's goals and preferences.

Inspectors wroteBased on observation, interview, and record review, drugs used in the facility were not labeled in accordance with currently accepted professional principles, to include the expiration date when applicable for 2 of 2 medication rooms and 1 of 3 medication carts observed. Medication rooms and carts contained insulin that was expired, and insulin and eye drops that were not dated when opened.

Inspectors wroteBased on record review and interview, the facility did not ensure assessments accurately reflected residents' status for 4 (R55, R59, R52, and R14) of 4 reviewed for Preadmission Screening and Resident Review (PASRR) with serious mental illness diagnosis. *R55, R59, R52, and R514 had PASRR Level I and Level II completed, and had diagnosis of serious mental illnesses, but this was not documented into the Minimum Data Set (MDS) comprehensive assessment at section A1500.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure staff were trained to safely use a hoyer lift with support bars. This was observed with 1 (R2) of 1 residents using this type of Hoyer Lift. R2 obtained a bruise by their eye due to staff using the Hoyer Lift incorrectly.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure food was stored and served in accordance with professional standards for food safety. *Staff did not test Sentinel sanitizing solution per manufacturer's instructions when testing the sanitizing sink used for dishwashing. Staff did not log or document testing results. This affected 136 out of 136 residents who receive food prepared by the facility kitchen. *The Unit refrigerator on 2E had multiple food items that were not labeled with resident's name. Open food was not dated. The refrigerator was unclean. There was not a current temperature log posted on the refrigerator and temperatures were not being documented since December of 2023. This had the potential to affected 41 of 41 residents who can use the Resident's unit refrigerator on 2E.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that food was prepared to conserve nutritive value. This has the potential to effect 8 of 8 residents on pureed diet. The Cooks Helper (CH-H) did not follow a recipe for preparing texture and modified consistency diet for pureed food.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 3 (R61, R66 & R63) of 5 sampled residents with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and provide dignity for residents. *R61 was observed multiple times with their catheter drainage bag system uncovered and laying on the floor. *R66 was observed multiple times with their catheter drainage bag system uncovered. *R63 was observed multiple times with their catheter drainage bag system uncovered and with drainage system port uncovered directly on the floor.

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. Licensed Practical Nurse (LPN) - E did not safely administer Insulin to 1 (R58) of 1 resident observed for insulin administration.

Inspectors wroteBased on interview and record review, the facility did not ensure proper antibiotic use for 1 (R46) of 4 resident's reviewed for antibiotic use. *R46 was prescribed an antibiotic prior to obtaining a respiratory panel. Results of the respiratory panel documented R46 was infected with the para-influenza virus, which does respond to antibiotics.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that its medication error rate was not 5 percent or greater. During observation of medication administration, the facility staff made medication errors with 2 (R58 and R10) of 7 residents observed for medication administration for a total of 2 errors of 31 opportunities for an error rate of 6.45%. ~ R58 was administered Novolin insulin that was expired. ~ R10 was administered Aspirin where the expiration date was illegible and was unable to be confirmed if it was expired or not.

Inspectors wroteBased on interview, record review and observation, the facility did not assure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles and include the expiration date when applicable in 3 of 3 Medication Carts and 2 of 2 Medication Storage Rooms reviewed for compliance. Surveyor observed undated, opened eye drops in 2NW Cart 1. Surveyor observed undated and unlabeled medications in 2NW Cart 1. Surveyor observed insulin that should have been refrigerated in 2NW Cart 1. Surveyor observed expired insulin in 2NW Cart 1. Surveyor observed 2 medications stored in latex gloves in 2NW Medication Room. Surveyor observed a salad in the medication fridge in the 2NW Medication Room. Surveyor observed nose spray with no opened on date in 3NW Cart 1. [...]

Inspectors wroteBased on interview, record review, policy review and review of facility documents, the facility failed to ensure two (Residents (R)1 and R3), of ten sampled residents were free of accidents. Specifically, R1 fell to the floor while unsupervised and sustained a fracture requiring surgical intervention, and R3 fell to the floor while unsupervised which resulted in a head laceration requiring medical treatment. In addition, both R1 and R3 were not provided individual interventions on their care plans to prevent the falls from occurring. The failure to provide adequate supervision and individual fall risk interventions placed R1 and R3 at risk for falls with injury.

Inspectors wroteBased on interview, record review, policy review and review of facility event reports, the facility failed to develop a baseline care plan to include individual approaches and interventions to prevent a fall for one (Resident (R) R1) of 10 sampled residents. Specifically, R1 fell to the floor while unsupervised which resulted in R1 sustaining a fracture requiring surgical intervention.