Martin Luther Care Center

Inspectors wroteBased on interview and document review, the facility failed to ensure resident personal fund accounts were insured with adequate surety bond coverage (a contract or promise by a surety or guarantor to pay a certain amount if a second party fails to meet the obligation) to cover the total account balance. This had the potential to affect 33 residents identified with a positive account balance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to honor resident rights to make choices about food preferences at meals for 1 of 1 resident (R12) reviewed for food choices.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff was familiar with and provided care according to the residents plan of care for 1 of 1 residents (R12) reviewed for meal assistance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure pain medication was administered timely for 1 of 1 resident (R12) reviewed for pain management.

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure that antihypertensive medications (used to treat high blood pressure) were given according to provider-ordered parameters to reduce the risk of adverse effects for 1 of 5 residents (R15) reviewed for unnecessary medication use. In addition, the facility failed to ensure active, duplicate medication orders were prevented with the potential for excessive medication use and correlating adverse effects for 1 of 5 residents (R3) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure adaptive equipment was provided for 1 of 1 resident (R12) who required weighted utensils and two-handled cups to encourage and promote self-feeding.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure written Physician's Orders for Life Sustaining Treatment (i.e., POLST) were accurately entered, transcribed and reflected in the medical record in a timely manner to help guarantee correct resuscitation measures (i.e., DNR or CPR) would be performed in accordance with resident wishes for 2 of 2 residents (R50, R321) reviewed for advanced directives. These findings constituted an immediate jeopardy (IJ) situation for R50 who would have received cardiopulmonary resuscitation measures (CPR) against her declared wishes. The IJ began on [DATE], when R50's POLST, indicating R50's wishes for Do not Resusitate (DNR) was signed by the medical provider and it wasn't changed within the facility' electronic Medical Record (EMR) system (i.e., banner) to reflect R50's wishes. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a safe, comfortable and homelike environment for 2 of 4 shower rooms reviewed for cleanliness. Also, facility failed to ensure resident walls were in good condition for 3 of 3 resident rooms (R4, R28, and R77 ) reviewed for concerns of peeling and chipped paint. In addition, the facility failed to ensure a hallway handrail was secured firmly to wall outside resident room.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and develop a bowel management program to meet voiced needs and wishes for 1 of 1 residents (R8) who needed digital stimulation; failed to ensure physician orders for diabetic monitoring devices were acted upon and implemented timely to prevent unnecessary distress (i.e., finger sticks, pain) for 1 of 1 residents (R8); failed to ensure a developed skin condition was assessed and appropriately treated for 1 of 2 residents (R1); failed to ensure a request for diet modification was appropriately and timely referred for evaluation for 1 of 1 resident (R57); and failed to ensure medical devices were consistently applied to reduce edema for 1 of 1 resident (R10) reviewed for edema management; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were securely stored safely and under direct observation of authorized staff in areas where residents, staff and guests could access medications in two medication carts affecting 2 of 4 units of the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was served in a timely manner to preserve desired temperatures of food for 4 of 4 residents (R1, R3, R40, R113) reviewed who expressed concerns for food temperatures and palatability. This had the potential to affect all residents who consumed food from the facility kitchenettes.

Inspectors wroteBased on interview and document review, the facility failed to ensure voiced complaints about nursing services were acted upon and, if needed, investigated or resolved for 1 of 1 resident (R57) reviewed who complained staff were placing two incontinent products on them at night, and they did not want a particular staff person to help with certain cares.

Inspectors wroteBased on interview and document reivew, the facility failed to ensure care planned interventions were followed for 1 of 1 resident (R57) reviewed for weight gain.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene and grooming (i.e., nail care, hair care, beard trimming) was provided for 2 of 3 residents (R20, R25) reviewed for activities of daily living (ADLs) and whom were dependent on staff for their care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a referral for potential cataract surgery was facilitated and/or completed in a timely manner to help improve vision and quality of life for 1 of 1 resident (R20) reviewed who was diagnosed with cataracts and expressed difficulty with his vision.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a range of motion (ROM) program was provided for 1 of 1 resident (R74) reviewed for mobility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure acute symptoms of distress or pain were recorded; and non-pharmacological interventions attempted or documented prior to the use of as-needed (i.e., PRN) narcotic medications to help promote continuity of care and care-planning for 1 of 5 residents (R50) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dental needs were coordinated with a dental provider for further care to reduce the risk of complication [i.e., cavities, oral pain] for 1 of 1 resident (R25) reviewed for dental care and services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure assessed and care-planned adaptive equipment for eating was provided to promote independence and personal hygiene during meals for 1 of 1 residents (R20) reviewed who needed special utensil handles.

Inspectors wroteBased on observation and interview, the facility failed to post survey results and/or a notice of the availability of such in areas of the facility that were prominent and accessible to the public. This had the potential to affect all 118 residents, families and visitors who may have wished to review the information without having to ask.

Inspectors wroteDuring observation and interview, the facility failed to implement interventions to ensure resident's personal care information was kept secured and out of public view when stored on 2 of 4 facility units with mobile medication carts. This had the potential to affect 9 of 9 residents (R8, R106, R110, R173, R174, R177, R325, R326, and R330) on the transitional care unit, and 3 residents (R70, R88, and R99) on the long-term care unit whose private and personal information was left unattended on medication carts left out in the hallway corridor.

Inspectors wroteBased on observations and interviews, the facility failed to wear proper personal protective equipment for residents who were on droplet precautions for one of ten residents (R8) reviewed for personal protective equipment and precautions.

Inspectors wroteBased on interview and record review the facility failed to follow 1 of 3 residents (R1's) Physician Orders for Life-Sustaining Treatment (POLST) do not resuscitate, do not intubate, allow for natural death when R1 was found unconscious in his bed and registered nurse (RN)-A initiated CPR. This deficient practice had the potential to prolong R1's right for a natural death encumbered by potential complications of unnecessary life saving measures. The IJ began on [DATE] at 2:45 a.m. when RN-1 was found unresponsive in his room and RN-A initiated chest compressions. The IJ was identified on [DATE]. The Administrator and the Director of Nursing were notified on [DATE] at 5:00 p.m. The IJ was removed on [DATE] and deficient practice was corrected on [DATE], prior to the start of the survey and therefore was issued at past noncompliance.

Inspectors wroteBased on interview and document review, the facility failed to monitor and obtain orders for surgical wound dressing changes for 1 of 3 residents (R1) reviewed for skin conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a comprehensive assessment for grab bars and implement interventions to ensure safety and mitigate the risk of entrapment or other injuries when using any mattress/bed types for 3 of 3 residents (R1, R2, R3) who had grab bars installed on their beds.

Inspectors wroteBased on interview and record review the facility failed to report an allegation neglect to the State Agency (SA) within 24 hours for 1 of 1 resident (R1). R1 was given the incorrect medications at the facility, which required R1 to be sent to the hospital for bradycardia (low heart rate), pain and anxiety.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to meet the needs for 1 of 4 residents (R4) reviewed for medication administration. R4 had an over-the-counter medication on his tray table that he had been taking for approximately two weeks, the facility failed to monitor his intake of the medication. This medication had an interaction with a prescription medication R4 was taking.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure expired and visibly molding produce was disposed to prevent serving expired food. This had potential to affect all residents, visitors and staff who consumed food from the main kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure appropriate infection control measures were implemented for direct resident care for 1 of 1 residents (R230) who was placed on enhanced barrier precautions. In addition, the facility failed to ensure clean personal and facility laundry was protected during transport and storage outside resident rooms. This had the potential to affect all 132 residents who utilized facility provided laundry services.

Inspectors wroteBased on observation and interview the facility failed to ensure two medication carts were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications. The deficient practice had the potential to affect twenty residents that resided on those units.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure timely assistance with elimination care was provided, when requested, to promote dignity and reduce the risk of complication (i.e., incontinence) for 1 of 2 residents (R182) reviewed for dignity with personal care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident medical records which contained private, medical, and personal information were kept private and not accessible to unauthorized personnel for 2 of 2 residents (R230 and R6) reviewed for privacy.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., nail care) was provided for 1 of 1 resident (R64) reviewed for activities of daily living (ADLs) who was dependent on staff for their care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure wound prevention treatment was implemented for 1of 1 resident (R36) who had a history of bilateral heel pressure areas and risk for skin breakdown.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively reassess after repeated refusals of an ambulation program and, if needed, develop interventions to reduce the risk of mobility loss for 1 of 1 resident (R36) reviewed for mobility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the use of bilateral, bed-mounted grab bars was comprehensively reassessed and, if needed, develop interventions to ensure safety while in bed for 1 of 1 resident (R62) reviewed who developed seizures after admission to the care center.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure staff provided cares according to standard of practice for gastrostomy tube care for 1 of 1 residents (R230) reviewed for tube feedings.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure complaint investigations regarding the facility during the three preceding years, and any plan of correction in effect with respect to the facility and posting of notice of availability of such reports were posted in areas of the facility that were prominent and accessible to the public. This had the potential to affect all 132 residents, families and visitors who may have wished to review the information.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the kitchen floors and mats were routinely and properly cleaned to ensure a sanitary kitchen environment. This had the ability to affect all 132 residents residing at the facility.