Lutheran Living Senior Campus

Inspectors wroteBased on clinical record review, staff interviews and facility policy review the facility failed to report an injury of unknown origin that resulted in serious bodily harm to the State Agency within the two-hour requirement for 1 of 1 resident (Resident #1) reviewed. The facility reported a census of 125 residents.

Inspectors wroteBased on clinical record review, hospice contract review, and staff interview, the facility failed to ensure that a hospice service agreement was signed with 1 of 2 hospice providers currently serving 1 of 4 residents on hospice (Resident #1); and failed to ensure required language addressing immediate notification of hospice administration in the event of alleged abuse by hospice staff was included in 1 of 1 signed agreement for a provider currently serving 3 residents (Resident#2, #3 and #5). The facility reported a census of 125 residents.

Inspectors wroteBased on clinical record review, facility policy review, resident representative interview and staff interview, the facility failed to ensure residents and/or their representatives were fully informed of the risks and benefits of taking psychotropic (medications that affect thought processes or behaviors) before the resident started taking the medication and when changes occurred for 2 of 5 residents (Residents #3 and Resident #47) reviewed for unnecessary medications. The facility reported a census of 117 residents.

Inspectors wroteBased on observations, clinical record review, facility policy review, family, resident and staff interviews, the failed to make repairs of damaged flooring and walls in a timely manner for 2 of 4 (Resident #53 and Resident #81) resident rooms sampled; and failed to dispose of an empty cleaning spray bottle from 1 of 4 (Resident #81) resident rooms. The facility reported a census of 117 residents.

Inspectors wroteBased on observations, clinical record review, facility policy review and staff interview, the facility failed to ensure staff completed hand hygiene and utilized Enhanced Barrier Precautions in an attempt to prevent the transmission of infections during resident care for 3 of 8 (Resident #2, Resident #3, and Resident #91) residents reviewed for infection control. The facility reported a census of 117.

Inspectors wroteBased on observation, facility record review, staff interview, and facility policy review, the facility failed to ensure the Daily Staffing posting contained required information and posted daily/seven days a week. The facility reported a census of 117 residents.

Inspectors wroteBased on clinical record review, facility self report, State of Iowa Administrative Hearings Findings, and staff interviews, the facility failed to perform behavioral health assessments for Resident #1 after he was served a 30 day involuntary discharge notice following an alleged assault on another resident. Resident #1 had a documented history of major depressive disorder and suicidal ideation and was placed on one to one (1:1) supervision after the alleged assault. On [DATE] the 1:1 supervision was discontinued to address a staffing shortage without Resident #1 being assessed. During the early morning hours of [DATE], with no 1:1 supervision, Resident #1 used items within reach and committed suicide hours before his scheduled discharge from the facility. The facility reported a census of 124 residents. [...]

Inspectors wroteBased on clinical record review, facility self report, State of Iowa Administrative Hearings Findings, staff and family interviews, and facility policy review, the facility failed to recognize and address potential statements and behaviors that indicated Resident #1's self harm risk after he was served a 30 day involuntary discharge notice following an alleged assault on another resident. Resident #1 had a documented history of major depressive disorder and suicidal ideation and was placed on one to one (1:1) supervision after the alleged assault. In the days leading up to his discharge, multiple staff members stated they observed Resident #1's potential signs of worsening depression or heard him verbalize comments of potential self-harm but did not report these concerns to facility management. [...]

Inspectors wroteBased on clinical record review, family and staff interviews, and policy review, the facility failed to conduct quarterly Care Conferences (CC) for 1 of 3 residents reviewed (#4). The facility reported a census of 124 residents.

Inspectors wroteBased on clinical record review, family and staff interviews, and policy review, the facility failed to provide timely physician and family notification for 1 of 3 residents (Resident #4) who experienced a newly documented open wound. The facility reported a census of 124 residents.

Inspectors wroteBased on clinical record review, family and staff interviews, the facility failed to provide timely interventions for 1 of 3 residents who experienced a newly documented open wound (#4). The facility reported a census of 124 residents.

Inspectors wroteBased on clinical record review, long term care ombudsman interview, and staff interview, the facility failed to cite the correct chapter of the Iowa Legislature State Regulations when issuing an involuntary discharge notice to 1 of 1 residents (Resident #1) reviewed. The facility reported a census of 124 residents.

Inspectors wroteBased on clinical record review, legal guardian interview, and staff interviews, the facility failed to notify the resident's guardian in a timely manner after a fall resulting in injury and transfer to the hospital for 1 of 3 residents reviewed. (Resident #1). The facility reported census was 120.

Inspectors wroteBased on observation, resident and staff interviews, and temperature testing, the facility failed to serve food at a palatable temperature for one dinner meal observed and for several residents served room trays on the evening meal in the rooms on the 600 Hall. The facility reported a census of 124 residents.

Inspectors wroteBased on record review, interviews, and the facility policy, the facility failed to report an alleged abuse incident for 1 of 1 residents reviewed for abuse (Resident #52). The facility reported a census of 124 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to ensure the Ombudsman notified of resident transfers to the hospital for 2 of 2 residents reviewed for hospitalization (Resident #37, Resident #110). The facility reported a census of 124 residents.

Inspectors wroteBased on record review, interviews, and the facility policy, the facility failed obtain a lab for a hemoglobin A1c per the provider's order for 1 of 25 residents reviewed for professional standards (Resident #35). The facility reported a census of 124 residents.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to ensure a medication cart remained locked when not in use for 1 of 7 medication carts. The facility reported a census of 124 residents.

Inspectors wroteBased on clinical record review, observations, facility video and staff interviews, the facility failed to ensure a resident with exit seeking behavior did not exit the facility without staff knowledge. (Resident #4) The facility reported census was 125. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 9/17/24 at 3:30 pm. The IJ began on August 4, 2024. Facility staff removed the Immediate Jeopardy on 9/24/24 through the following actions: - Resident placed on 1:1 observation on 8/4/24 until he was moved to the locked Memory Care Unit on 8/5/24. - Neuro checks initiated, witness statement obtained, and notifications made on 8/4/24. - Elopement assessment and care plan updated 8/5/24. - Staff education on elopement and documentation began 8/4/24. - Residents wander guard immediately checked for functionality on 8/4/24. [...]

Inspectors wrote; Based on observations, clinical record review, resident and staff interviews, the facility failed to ensure residents are provided incontinence care in accordance with professional standards of practice. (Resident #19, #20) The facility reported census was 125.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to properly identify residents prior to administration of medications, failed to clarify medication orders, failed to initiate medication orders timely and failed to recognize medication errors when they occur and properly notify physicians of such errors, all in accordance with a professional standards of practice. (Residents #3, #7) The facility reported census was 125.

Inspectors wroteBased on clinical record review the facility failed to notify a resident's physician upon discovering a positive COVID infection. (Resident #8) The facility reported census was 125.

Inspectors wroteBased on clinical record review, personnel records, medical examiner interview and staff interviews, the facility failed to provide adequate staff and supervision to assist a resident who called out for help in a timely manner for 1 of 5 residents (Resident #1) reviewed for safety. Per staff interview, Resident #1 called out for help on [DATE] at approximately 4:30 AM, and staff were unable to respond for up to 10 minutes. The resident subsequently found face down in bed, feet on the floor, unresponsive. The facility reported a census of 129 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on [DATE] at 5:35 p.m. The IJ began on February 11, 2024, when Resident #1 found unresponsive. Facility staff removed the Immediate Jeopardy on [DATE] through the following actions: a. [...]

Inspectors wroteBased on interviews, clinical record review, facility policy review and facility investigation review, the facility failed to ensure a resident was not subjected to involuntary seclusion when a staff member had used verbal threats to impose the understanding to a resident that she was not allowed to leave her room. This deficient practice resulted in Resident #385 displaying behaviors of anxiety, tearfulness, and fear of the staff member that imposed the involuntary seclusion to the residents room for one of four residents reviewed for abuse (Resident #385). This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of a resident who resided at the facility. The facility reported a census of 140 residents. Findings Include: [...]

Inspectors wroteBased on clinical record review, staff interview, Facility Investigation Review and facility policy review the facility failed to thoroughly and timely investigate a resident's allegations of mean/aggressive treatment and involuntary seclusion by a facility staff member, failed to separate residents from an alleged perpetrator after staff had become aware of allegations, and failed to maintain thorough documentation regarding investigation into the resident's allegations for one of four residents reviewed for abuse (Resident #385). This deficient practice resulted in an Immediate Jeopardy to the health and safety of a resident who resided at the facility. The Facility had a census of 140. Findings Include: [...]

Inspectors wrote5. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS documented the resident needed extensive assistance with two plus person physical assist for bed mobility, transfers, and dressing. The MDS revealed medical diagnosis of heart failure, hypertension, and hemiplegia/hemiparesis. The Care Plan identified a focus problem of skin integrity for actual complications with impaired skin integrity including skin tears, bruising and pressure related to current medical and physical status with initiated date of 9/13/22. The interventions were listed as follows; documented medications, labs, and treatments as ordered; [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure consistent documentation of code status to direct staff clearly on Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) orders for 4 of 5 residents reviewed for Advance Directives (Resident #48, #118, #128, #438). The facility reported a census of 140 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview the facility failed to complete comprehensive care plans to reflect care given and failed to consistently provide care conferences on a quarterly basis for 4 of 7 residents reviewed for care plan conferences and care plan revision (Resident #101, Resident #5, Resident #7, Resident #24). The care plan for Resident #101 did not include goals and interventions for 12 focus areas identified. The care plan for Resident #5 did not include interventions for activities of daily living (ADL). The facility reported a census of 140 residents.

Inspectors wroteBased on staff interviews, resident interviews, record review and policy review. The facility failed to ensure sufficient staffing to meet resident's needs for 6 of 29 residents reviewed in the sample (#7, #26, #27, #48, #52, #60). The facility reported a census of 140.

Inspectors wroteBased on observation, resident interview, and staff interviews the facility failed to protect and value resident's private space when they entered a resident room with a closed door without knocking and waiting for permission to enter and failed to ensure residents were treated in a dignified manner for two of four resident's reviewed for dignity (Resident #8, Resident #56). The facility reported a census of 140.

Inspectors wroteBased on clinical record review, staff interview, Facility Investigation Review and facility policy review the facility failed to notify the Power of Attorney or family members regarding allegations of mean and aggressive treatment by a facility staff member resulting in a possible injury to her knee and involuntary seclusion, for one of three residents review for notification. (Resident#385). The facility failed to protect resident during the facility investigation. The facility reported a resident census of 140. Findings Include: The Quarterly Minimum Data Set (MDS) assessment for Resident #385 dated 07/05/2023 revealed the resident scored 8 out of 15 on a Brief Interview for Mental Status exam, which indicated the resident was severally cognitively impaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for two of four residents reviewed for abuse. (Resident #64, Resident #84). The facility reported a census of 140 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure allegations of abuse were reported within required regulatory timeframe for three of four residents reviewed for abuse (Resident #64, Resident #84, Resident #385). The facility reported a census of 140 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure thorough documentation in the clinical record for a resident's transfer to the hospital for three of seven residents reviewed for hospitalization (Resident #7, Resident #60, Resident #124). The facility reported a census of 140 residents.

Inspectors wroteBased on clinical record review and staff interviews the facility failed to ensure resubmission of the Preadmission Screening and Resident Review (PASARR) following change in medical diagnoses for one of two residents reviewed for PASARR (Resident #47). The facility reported a census of 140 residents.

Inspectors wroteBased on record review, staff interview and facility policy review the facility failed to complete a Preadmission Screening and Resident Review on 1 out of 1 residents reviewed (Resident #69). The facility reported a census of 140 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure timely completion of a baseline Careplan for two of twenty-eight residents reviewed for baseline Careplan (Resident #7, Resident #124). The facility reported a census of 140 residents.

Inspectors wroteBased on interview, observation, record review, and facility policy review the facility failed to provide showers twice weekly for 1 of 3 residents reviewed for ADLs (Activities of Daily Living) (Resident #7). The facility reported a census of 140.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to assess the pain in the foot and knee after a reported incident and failed to assess the foot after an incident while transferring a resident in the shower chair for 2 out of 4 residents reviewed for assessment and intervention (Resident #7 and Resident #385). The facility reported a census of 140.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to prevent the catheter bag from touching the floor for 1 of 3 residents reviewed for urinary catheters (Resident #8). The facility reported a census of 140.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to publicly post the required nursing staff requirements. The facility reported a census of 140 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure documented non-pharmacological interventions attempted prior to the administration of anti-anxiety medication for one of five residents reviewed for unnecessary medications (Resident #124). The facility reported a census of 140 residents.

Inspectors wroteBased on staff interview, human resources file review, and document review, the facility failed to ensure a staff member held needed certification and current educational requirements to pass medications in long term care setting for one of three employee files reviewed (Staff JJ). The facility reported a census of 140 residents.

Inspectors wroteBased on observation, staff interviews and policy review, the facility failed to provide 1 of 4 residents reviewed with accessibility of a functioning call system device to allow resident to staff communication (Resident #52). The facility reported a census of 140. The Quarterly Minimum Data Set (MDS) for Resident #52 dated 06/27/23 listed diagnoses included renal disease, disc degeneration, pain and dementia. The MDS section for Brief Interview of Mental Status (BIMS) scored 12 indicated resident cognition is moderately intact. On 9/16/23 a new admission MDS documented resident #52 readmitted from acute hospital stay. The care plan was updated 9/16/23 indicated Resident #52 returned from hospital stay related to a left hip fracture. The care plan directed staff to follow physical therapy orders, to provide one or two assistance with bed mobility assistance. [...]

Inspectors wroteBased on staff interview, review of CMS-2567 reports, and facility QAPI (Quality Assurance and Performance Improvement) Plan, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification and complaint survey previously identified during surveys completed in the last fifteen months. The facility reported a census of 38 residents.