Lutheran Village at Wolfcreek

Inspectors wroteBased on observation, staff interview, review of a medication expiration list, review of a medication package insert, and review of a facility policy, the facility failed to ensure medications and biologicals were properly dated and discarded after expiration. This had the potential to affect all 57 residents in the facility. The facility census was 57.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure oxygen tubing was changed and labeled as required, and failed to ensure oxygen was administered at the appropriate rate as ordered. This affected four (#20, #12, #21, and #39) of six residents reviewed for oxygen therapy. The facility census was 57. Findings Include: 1. Review of Resident #20's medical record revealed an admission date of 03/21/24. Diagnoses included pulmonary embolism, chronic obstructive pulmonary disease (COPD), osteoarthritis, anxiety disorder, morbid obesity, depression, and polyneuropathy. Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #20 was cognitively intact. [...]

Inspectors wroteBased on observation, staff interview, medical record review, review of manufacture instructions, review of a facility medication guide, and review of facility policies, the facility failed to ensure staff wore appropriate personal protective equipment when providing care for residents on enhanced barrier precautions, failed to ensure medical equipment was properly sanitized between resident use, failed to ensure hand hygiene was performed during resident care, and failed to an insulin pen was sanitized prior to applying a needle for administration. This affected four (#41, #19, #23, and #1) of four residents reviewed for infection control measured during resident care. The census was 57.

Inspectors wroteBased on medical record review, staff interview, facility policy review, the facility failed to ensure a resident code statue was documented across all medical records. This affected two (#10 and #36) of 28 residents sampled for record review. The facility census was 57.

Inspectors wroteBased on observation, resident and family interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure residents who were not able to speak English had a consistent means of communication for their care needs. This affected one (#1) of two residents reviewed for communication. The facility census was 57.

Inspectors wroteBased on medical record review, resident and staff interview, and review of a facility policy, the facility failed to ensure residents who were dependent on staff for care received adequate and timely care to maintain oral hygiene. This affected one (#6) of four residents reviewed for activities of daily living. The facility census was 57. Findings Include:Review of Resident #6's medical record revealed an admission date of 08/05/25. Diagnoses included fusion of the cervical spine, fracture of cervical vertebrae subsequent encounter, fracture of tibia subsequent encounter, pulmonary embolism, muscle wasting, and morbid obesity. Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #6 was cognitively intact. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure interventions for prevention of pressure ulcers were applied as ordered. This affected one (#7) of four residents reviewed for pressure ulcers. The facility census was 57. Findings Include:Review of Resident #7's medical record revealed an admission date of 02/10/25. Diagnoses included dementia, chronic obstructive pulmonary disease, Alzheimer's disease, major depressive disorder, left heel stage four pressure ulcer, unstageable pressure ulcer of her right heel, and anxiety disorder. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 required maximal assistance with eating, and was dependent on staff for toilet use, bathing, dressing, bed mobility, and transfers. [...]

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected one (#21) of five residents reviewed for fall interventions. The facility census was 57.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure medications were administered per physician's order. This affected one (#41) of four reviewed for medication administration. The facility census was 57.

Inspectors wroteBased on observations, staff interview, review of sanitizer log and policy review, the facility failed to ensure foods were stored in a safe and sanitary manner. In addition, the facility failed to ensure the chemical dish washing machine had the proper chemical sanitizer level for effective disinfection of dishes and utensils. This had the potential to affect 52 residents who receive food from the kitchen. Three residents (#37, #43 and #53) received no food by mouth and thus no food from the kitchen. The facility census was 55.

Inspectors wroteBased on observation, staff interview, resident interview, record review and review of policy, the facility failed to ensure residents were treated with dignity and respect. This affected two (#20 and #48) of three residents reviewed for dignity. The facility census was 55.

Inspectors wroteBased on medical record review, observation, and resident and staff interview, the facility failed to ensure a resident was evaluated for safe use of a motorized wheelchair and provided a foot pedal for the manual wheelchair. This affected one (#5) of one resident reviewed for accommodation of needs. The facility census was 55.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to notify the physician when medications were not being administered per physician's orders. This affected one (#43) of five residents reviewed for medications. The facility census was 55.

Inspectors wroteBased on medical record reviews, observations, resident and staff interviews, the facility failed to ensure residents dependent on staff to provide assistance with captivities of daily living (ADLs) was provided the required assistance. This affected two (#36 and #38) of six residents reviewed for ADLs. The facility census was 55.

Inspectors wroteBased on medical record review, observation, resident and staff interview, and review of policy, the facility failed to ensure activities of interest were provided to residents who stayed in their room. This affected two (#36 and #43) of three residents reviewed for activities. The facility census was 55.

Inspectors wroteBased on record review, observation, staff interview, and resident interview, the facility failed to provide adequate care and treatment for a resident experiencing edema. This affected one (#17) of 16 residents reviewed for quality of care and treatment. The facility census was 55.

Inspectors wroteBased on medical record review, observation, resident's friend interview, resident interview, and staff interview, the facility failed to ensure residents received timely incontinence care. This affected one (#36) of one residents reviewed for incontinence care. The facility census was 55.

Inspectors wroteBased on medical record review, observation, resident and staff interviews, review of resident's meal ticket and review of policy, the facility failed to ensure a resident's physician ordered therapeutic diet was provided as ordered. This affected one (#17) of two residents reviewed for nutrition. The facility census was 55.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to administer medications per physician's orders. This affected one (#43) of five residents reviewed for medications. The facility census was 55.

Inspectors wroteBased on medical record review, resident and staff interview, review of Medscape medication prescribing information, and review of policy, the facility failed to ensure two (#36 and #49) residents did not receive antipsychotic medications without an appropriate diagnosis or treatment of a specific condition. In addition, the facility failed to ensure one resident's (#48) as needed (PRN) use of anxiety medications were not utilized beyond 14 days without physician review and failed to update the physician order with an end date once reviewed by the physician. This affected three (#36, #48, and #49) of five residents reviewed for unnecessary medications. The facility census was 55.

Inspectors wroteBased on observation, staff interview, medical record review, review of drug manufacturer's instructions, and review of policy, the facility failed to ensure insulin was administered as ordered. This affected one resident (#53) of ten residents observed during medication administration. The facility census was 55.

Inspectors wroteBased on medical record review, observation, staff interview, review of manufacturer's drug facts labels, and review of policy, the facility failed to ensure medications were securely stored. This affected one (#20) of one resident reviewed for medication storage. The facility identified one (#42) cognitively impaired and independently mobile residing on the B Hall. The facility census was 55.

Inspectors wroteBased on observation, staff interview, and review of policy, the facility failed to ensure hand hygiene was performed after providing resident care during meal tray service. This affected two (#3 and #315) of 52 residents observed during meal service. The facility census was 55.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident's vaccination records and screenings were documented in the resident's personal medical record. This affected four (#20, #37, #38, and #42) of five residents reviewed for immunizations, with the potential to affect all 55 residents. The facility census was 55.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure residents were equipped with appropriately assessed wheelchairs. This affected one (Resident #44) of 26 residents reviewed for the provision of assistive devices. The facility census was 107.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure residents who required staff assistance with transfer had their choice of rising time respected. This affected two (Residents #92 and #71) of three residents reviewed for choices. The facility census was 107. Findings Include: 1. Review of Resident #92's medical record revealed an admission date of 08/16/17. Review of Resident #92's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. She required extensive assistance with bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Review of Resident #92's care plan revised 12/04/19 revealed supports and interventions for self-care deficit. Resident #92's preferences included needing one to two person physical assistance with transferring, and dressing. [...]

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure a resident with contractures had a splint applied as ordered. This affected one (Resident #64) of one reviewed with contractures. The facility identified two residents with contractures. The facility census was 107.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to implement nutrition recommendations following a significant weight loss. This affected one (Resident #17) of four residents reviewed for nutrition.

Inspectors wroteBased on observation, staff interview, resident interview, and record review, the facility failed to ensure fluid restrictions were in place and being monitored. This affected one (Resident #3) reviewed for dialysis. The facility identified three residents who have orders for dialysis treatments and require fluid restrictions.