Lutheran Sunset Home

Inspectors wroteBased on observation, review of the facility's policy, review of facility housekeeping checklist, and resident and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 5 of 19 sampled residents (Resident #10, #13, #42, #47, and #82) Failure to maintain clean equipment and ensure a safe, clean, and sanitary environment may result in injuries, diminish the homelike living area for residents, and does not promote overall quality of life.

Inspectors wroteBased on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure dishware and eating utensils are properly cleaned and sanitized in 1 of 1 kitchenette (Special Care Unit) utilizing a mechanical dish-washing machine. Failure to ensure the mechanical dishwashing machine reaches the proper temperatures for the wash and final rinse cycles may result in unclean and unsanitized dishware and eating utensils.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity for 2 of 19 sampled residents (Resident #2 and #8). Failure to provide privacy to residents while in their room has the potential to affect the residents' psychosocial wellbeing and does not enhance the residents' quality of life.

Inspectors wroteBased on record review, review of the facility reported incident (FRI) reports, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from resident-to-resident altercations for 2 of 2 sampled residents (Resident #2 and #37) subjected to physical and sexual abuse from other residents. Failure to protect residents from physical or sexual abuse placed Residents #2 and #37 and all other residents at risk for mental and emotional distress, and injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to report potential abuse for 1 of 2 sampled residents (Resident #2) and 1 supplemental resident (Resident #40) reviewed for resident-to-resident altercations. Failure to report potential abuse to the State Survey Agency (SSA) placed Resident #2 and all other residents at risk for possible abuse and/or physical injury.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident records contained the hospice election form for 1 of 1 closed record (Resident #85) who received hospice services. Failure to obtain the election form may have limited staff's ability to ensure coordination of care between the facility and the hospice.

Inspectors wroteBased on observations, review of the Resident Council minutes, and resident interview, the facility failed to follow standards of practice for infection control for 1 of 1 sampled resident (Resident #82) who received nebulizer treatments. Failure to ensure nebulizer masks and tubing are on a clean surface may result in contamination of the items and lead to respiratory infections.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 18 sampled residents (Resident #2, #33, #75, and #236) and 2 supplemental residents (#9 and #43) observed. Failure to practice infection control standards related to enhanced barrier precautions (EBP), transmission-based precautions (TBP), and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 18 sampled residents (Resident #24 and #35) and 1 supplemental resident (Resident #40). Failure to accurately code the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 18 sampled residents (Resident #1 and #35). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, record review, review of manufacturer's instructions for use, and staff interview the facility failed to ensure staff followed standards of practice for 2 of 2 residents (Resident #33, and #235) who required rapid acting insulin. Failure to administer rapid acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 3 sampled residents (Resident #75) observed during transfers. Failure to utilize a gait belt during transfers placed the resident at risk for falls and/or injury.

Inspectors wroteBased on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure food is served and stored in accordance with professional standards for food service sanitation in 1 of 1 kitchen (main kitchen). Failure to ensure a reach-in freezer remains free of frozen water/condensation and ensure proper glove usage when serving ready-to-eat foods has the potential to result in foodborne illness and may result in adverse consequences for residents, visitors, and staff.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure the coverage of 1 of 1 surety bond provided the required coverage of all personal funds for residents who deposited money with the facility. Failure to ensure the security bond covered all funds entrusted to the facility may result in the residents suffering financial losses secondary to the facility failing to hold, safeguard, manage, and/or account for their funds.

Inspectors wrote1. Based on record review, resident and staff interviews, and review of a facility reported incident, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #1) reviewed for an accident with subsequent injury. Failure to follow facility policy for proper use of a stand-lift resulted in injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to report alleged violations involving neglect to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to report allegations and submit investigation results placed all residents at risk for neglect.

Inspectors wroteBased on observation, facility documentation, and staff interview, the facility failed to serve, prepare, and store food in a safe and sanitary manner for 1 of 1 kitchen. Failure to discard spoiled food and protect dishware from contamination has the potential to result in foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 1 of 20 sampled residents (Resident #132) reviewed for advance directives. Failure to ensure the medical record accurately reflected the resident's code status limited the facility's ability to communicate to direct care staff and emergency personnel the resident's choice in the event of a medical emergency.

Inspectors wroteBased on observation, record review, review of a facility reported incident, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 3 of 20 sampled residents (Resident #12, #30, and #50). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on review of Quality Assurance and Performance Improvement (QAPI) meeting minutes, facility policy, and staff interview, the facility failed to ensure participation by the medical director for 2 of 4 quarterly meetings (February 16, 2023 and August 17, 2023) reviewed. Failure to ensure the medical director participates in the facility's Quality Assurance activities deprived the committee of the physician's unique contributions for analyzing and correcting problems with identified resident care areas.