Lutheran Nursing Home

Inspectors wroteBased on interview and record review, the facility failed to report a resident-to-resident altercation when Resident #3 hit Resident #14 out of 14 sampled residents. The facility census was 84 residents. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an investigation was completed after a resident-to-resident altercation occurred when Resident #3 hit Resident #14 out of 14 residents sampled residents. The facility census was 84 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure International Normalized Ratio (INR- used to monitor the effectiveness of blood thinning drugs) tests were ordered upon admission and completed for one sampled resident (Resident #4) out of 14 sampled residents. The facility census was 84 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate behavioral monitoring was in place for one sampled resident (Resident #3) out of 14 sampled residents. The facility census was 84 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct quarterly Criminal Background Checks for eight out of 10 sampled employees (Employees AA, BB, CC, DD, EE, FF, GG and HH). The facility census was 70 residents. Review of the facility Background Screening Investigations policy dated 8/23/24 showed: -The Employee Disqualifications List (EDL) is maintained through the Department of Health and Senior Services (DHSS).-The EDL is checked prior to date of hire and quarterly thereafter.1. Review of Employee AA's personnel record showed:-His/her hire date was 1/13/25.-His/her EDL check date was 1/13/25.-His/her quarterly EDL checks were due in April 2025 and July 2025 and were not completed.2. Review of Employee BB's personnel record showed:-His/her hire date was 2/17/25.-His/her EDL check date was 2/12/25.-His/her quarterly EDL check was due in May 2025 and was not completed.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident's (Resident #9) urine sample was picked up by the laboratory according to acceptable standards of practice and failed to ensure effective coordination with the lab, thereby delaying necessary treatment, out of 18 sampled residents. The facility census was 70 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #12) received timely vision services out of 18 sampled residents. The facility census was 70 residents. Review of the facility's policy titled Visually Impaired Resident, Care of dated March 2021 showed:-Assistive devices to maintain vision included glasses, contact lenses, magnifying lens, and any other device used by the resident to assist with visual impairment.-It was not required of the facility to provide devices to assist with vision, but it was their responsibility to assist the resident and representatives in locating available resources, scheduling appointments, and arranging transportation to obtain needed services.-Residents who have lost or damaged their devices would be assisted in obtaining services to replace the devices.1. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure appropriate care for one sampled resident (Resident #2) with a Gastrostomy (G-Tube- an opening into the stomach from the abdominal wall, made surgically for the introduction of food) out of 18 sampled residents. The facility census was 70 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess and provide supportive interventions for two sampled residents (Resident #11 and #40), with a diagnosis of 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) out of 18 sampled residents. The facility census was 70 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two sampled Nursing Assistants (NA) (NA B and NA C) had completed the state approved Certified Nursing Assistant (CNA) training program within four months of his/her facility employment. The facility census was 70 residents. Review of the facility Nursing Assistant Qualifications and Training Requirements policy dated August 2022 showed:-The facility would not employ any individual as a Nursing Assistant for more than four months unless that individual had completed a training program and competency evaluation approved by the state.1. Review of NA B's personnel file showed:-His/her hire date was 2/17/25.-He/She had worked at the facility for over five months.-There was no record of the employee having completed CNA training.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate follow-up was completed for pharmacy recommended gradual dose reductions (GDR- stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or medication can be discontinued) for two sampled residents (Resident #2 and #6) out of 18 sampled residents. The facility census was 70 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #12) was referred to an oral surgeon in a timely manner out of 18 sampled residents. The facility census was 70 residents. Review of the facility's policy titled Dental Services dated December 2016 showed:-Social Service representatives would assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible.-All dental services provided were recorded in the resident's medical record. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to follow the facility policy and the resident's care plan by transferring one sampled resident, (Resident #1) without using two staff or using a gait belt, out of five sampled residents. The facility census was 54 residents. The Administrator was notified on 7/8/24 Past Non-Compliance which occurred on 6/23/24. An all nursing staff in-service was completed on resident transfers prior to start of the next shift. The deficiency was corrected 6/25/24. Review of the facility policy for Safe Lifting and Movements of Residents revised July 2017 showed: -The purpose of the policy was to protect the safety and well-being of staff and residents, and to promote quality care, using appropriate techniques and devices to lift and move residents. -The manual lifting of residents was to be eliminated whenever feasible. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure three sampled residents (Resident #1, Resident #3, and Resident #4) were treated with dignity and self-determination related to their bathing/showering preferences out of five sampled residents. The facility census was 62 residents. Review of the facility's undated policy titled Bathing Policy showed: -It was the responsibility of the licensed nurse and/or nursing assistants to ensure baths/showers were completed. -Residents would receive a whirlpool bath, shower, or bed bath at least weekly and pro re nata (PRN- as needed). -Nursing would update bathing schedule as needed. 1. Review of Resident #1's Face Sheet showed he/she admitted to the facility with the following diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to have a process in place to ensure Cardiopulmonary Resuscitation (CPR- an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who was in cardiac arrest) certified staff were available on all shifts. The facility census was 47 residents. Review of facility's undated policy Cardiopulmonary Resuscitation (CPR) showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for applying Sequential Compression Devices (SCD- sleeves with separated areas or pockets of inflation, which works to squeeze on the appendage in milking action) for one sampled resident (Resident #44) out of 12 sampled residents. The facility census was 47 residents. A policy for SCD use was requested and not received at the time of exit. 1. Review of Resident #44's Face Sheet showed he/she was admitted to the facility on [DATE] with following diagnoses: -Lymphedema (swelling in the arms or legs caused by lymphatic system blockage). -Chronic pain. Review of the residents Annual Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff for care planning) dated 8/2/23 showed: -He/she was cognitively intact. -He/she needed total two person assist with transfers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate documentation and reconciliation of narcotic pain medications for two sampled residents (Resident #35 and #38); and to notify the physician of unavailable pain medication in a timely manner for one sampled resident (Resident #38) out of 12 sampled residents. The facility census was 47 residents. Review of the facility's undated Oral Medication Administration policy showed: -Review the five rights of medication administration including the right drug name, right drug dose, and right time. -Check narcotic record for previous drug count and compare with supply available. -Compare Medication Administration Record (MAR) with prepared drug label/container. -Record administration of oral medication on MAR by placing nurse's initials or signature. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control protocol for cross-contamination with the placement of the resident's urinary catheter drainage bag (a bag that collects urine that is attached to a tube that is inside the bladder) for one sampled resident (Resident #38) out of 12 sampled residents. The facility census was 47 residents. Review of the facility's undated Infection Control and Safe Practice Policy showed the facility will apply standard precautions practices at all times, to as far as possible to prevent the transmission of infection. 1. Review of Resident #38's Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Obstructive and Reflux Uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or family were notified when a staff or resident in the facility tested positive for COVID (a new disease caused by a novel (new) coronavirus) for five sampled residents (Residents #3, #16, #39, #47, and #50) out of 15 sampled residents. The facility census was 58 residents. A policy for notification of residents and family for positive COVID staff and/or residents was requested but not received at the time of exit. 1. Record review of Resident #3's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/30/22 showed: -He/She was admitted to the facility on [DATE]. -He/She had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating he/she was cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the criminal background checks (CBC) requested for four employees (Employees B, D, E and F) out of 10 sampled employees, pulled information from the Missouri (MO) Highway Patrol as outlined in state statute 43.540. This deficient practice had the potential to affect all facility residents. The facility's census was 58 residents. Record review of facility policy titled Resident Abuse/Neglect/Exploitation Policy and Procedure dated 12/30/16 showed: -Screening Policy: --All potential employees shall receive a criminal background check. --Attempts shall be made to obtain information from current and previous employers as listed on the employment application. -Procedure: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen review (DRR) of each resident was completed at least once a month by a licensed pharmacist and/or to maintain the list of residents with no irregularities and to ensure DRR were completed or failed to maintain the DRR recommendations and responses for seven sampled residents (Residents #35, #50 #10, #5, #2, #21, and #14) out of 15 sampled residents. The facility census was 58 residents. Record review of the facility's DRR policy dated November 2017 showed: The DRR was to be completed by a pharmacist on all residents monthly. -Following the completion of the DRR, the pharmacist shall: --Complete the consultant pharmacist DRR form that is kept in each chart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Stage II Pressure Ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) to the left heel was kept clean and covered with a dressing per the physician's order for one sampled resident (Resident #48) out of 15 sampled residents. The facility census was 58 residents. Record review of the facility's undated policy titled Wound Care Protocol showed: -Certified Nursing Assistant (CNA), Bath Aide, and other staff were to report skin issues to the charge nurse. -Treatments were to be completed per the physician's order. -The wound nurse was to document on wounds weekly on the back of the resident's treatment sheet. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a significant medication error did not occur during the administration of insulin by not providing food or beverage with carbohydrates within 10 minutes of insulin administration for one sampled resident (Resident #24) out of 15 sampled residents. The facility census was 58 residents. Record review for the product insert for Novolog dated October 2021 showed Novolog is a fast-acting insulin. Eat a meal within five to ten minutes after taking it. A facility policy for insulin administration was requested and not provided. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the narcotic count sheet log was completed each shift; and to ensure staff properly discarded narcotics (substances with a high probability for physical and/or psychological dependence) for one sampled resident (Resident #50) out of 15 sampled residents. The facility census was 58 residents. Record review of the facility's undated policy titled Disposition of Drugs from the Floor showed controlled drugs were to be destroyed using the Drug Buster (a solution in a jug that dissolves medications on contact) in the presence of two licensed nurses and recorded appropriately on the Narcotic Count Sheet. A policy for the Daily Narcotic Count Sheet was requested and not received. 1. Record review of the facility's Daily Narcotic Count Sheet showed: -January 2022 logs missing 45 signatures out of 434 opportunities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dental care was offered once yearly for one sampled resident (Resident #4) out of 15 sampled residents. The facility census was 58 residents. A dental policy was requested and not received. 1. Record review of Resident #4's face sheet showed he/she was admitted on [DATE]. Record review of the resident's care plan dated 1/6/22 showed: -He/she had his/her natural teeth with some missing. -The facility should ensure he/she received dental consults as needed. Record review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/5/22 showed no dental concerns. Record review of the resident's Social Services Progress Notes showed: -On 6/9/20, there were no oral concerns. -On 9/8/20, there were no oral concerns. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures to ensure all staff either completed the COVID-19 (a new disease caused by a novel (new) coronavirus) vaccination series or had documentation of a granted exemption from the vaccination on file for three out of eight sampled staff. Facility records showed 95.9% of facility staff were either fully vaccinated or had an approved exemption or delay. The facility had zero COVID-19 positive residents in the previous 4 weeks. The facility census was 58 residents. Record review of the facility undated Vaccine Mandate Policy showed: -As of 1/4/22, all staff and contracted staff will have completed their primary vaccination series. -This does not include staff that has been granted an exception from the COVID-19 vaccination. [...]