Saint Luke Lutheran Home

Inspectors wroteBased on record review, and staff interview the facility failed to ensure annual evaluations was completed. This had the potential to affect all 121 residents. The facility census was 121.

Inspectors wroteBased on observation, interview, and facility policy, the facility failed to maintain a sanitary kitchen This had the potential to affect all residents receiving meals from the kitchen. The facility indicated three (Residents #1, #63 and #136) do not receive meals from the kitchen as they receive nothing by mouth. The facility also failed to ensure resident room and unit refrigerators were monitored and maintained in a safe manner. This affected five (Residents #25, #85, #100, #101, and #110) and had the potential to affect 25 (Residents #6, #16, #22, #25, #26, #30, #34, #37, #38, #41, #43, #58, #74, #75, #82, #85, #97, #100, #101, #102, #104, #109, #110, #118, and #123) residents the facility indicated had room refrigerators. The facility census was 121.

Inspectors wroteBased on record review and interview, the facility failed to ensure an effective administration staff. This finding had the potential to affect all residents residing in the facility. The facility census was 121.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure staff provided assistance with activities of daily living (ADL's) including toileting, showering and shaving for Residents #1, #4, #13, and #57. This affected five (#1, #4, #13, and #57) of 14 residents reviewed for ADL's. The facility census was 121.

Inspectors wroteBased on medical record review, interview and policy review the facility did not honor dietary preferences for three (Residents #8, #14, and #45) residents and did not tell or offer the family of Resident #8, who was cognitively impaired, the option to complete weekly menus. This had the potential to affect all resident receiving meals from the facility. The facility indicated three residents (Residents #1, #63 and #136) who received nothing by mouth. The facility census was 121. Findings Include:1. Review of the medical record for Resident #8 revealed an admission date of 09/08/23. Diagnoses included but were not limited to Alzheimer's disease, displaced comminuted fracture of shaft of left humerus with routine healing, and age-related physical debility. [...]

Inspectors wroteBased on observation, interview and review of the facility policy the facility failed to ensure palatable meals for residents receiving meals from the kitchen. This affected two (#14 and #134) and had to the potential to affect all residents who received meals from the kitchen. The facility identified three residents (#1, #63 and #136) who received nothing by mouth. The facility census was 121.

Inspectors wroteBased on observation, interview and review of maintenance logs and repair invoices, the facility failed to ensure kitchen equipment repairs were completed timely. This had the potential to affect all residents receiving meals from the kitchen. The facility indicated three (Residents #1, #63 and #136) receiving nothing by mouth. The facility census was 121.

Inspectors wroteBased on observation, staff interview, family interview, and review of facility policy, the facility failed to ensure a clean and sanitary environment and failed to ensure patient care equipment was maintained in good repair. This finding affected six (Residents #4, #34, #69, #87, #134 and #137) of eleven resident rooms reviewed for environmental concerns. The facility census is 121.

Inspectors wroteBased on observation, record review, staff interview, and review of facility policy, the facility failed to ensure Resident #10 had privacy during care. This affected one (#10) of two residents observed for care. The facility census was 121.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident rooms were clean, sanitary and that residents had clean linens. This affected two (#85 and #110) out of three residents observed for a homelike environment. The facility census was 121.

Inspectors wroteBased on record review, interviews, review of in-room videos, review of the facility self-reported incident, and review of facility policy, the facility failed to ensure Resident #117 was free from physical abuse. This affected one (#117) of four residents reviewed for abuse. The facility census was 121.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and policy review, the facility failed to implement their abuse policy when Resident #6's allegation of abuse and staff concerns regarding the neglect of care for Resident #10 were not reported to the Administrator. Additionally the facility failed to ensure Resident #47's injury of unknown origin were reported to the State Agency. This affected three (#6, #47 and #10) of four residents reviewed for abuse. The facility census was 121.

Inspectors wroteBased on record review, interview, review of facility Self-Reported Incidents (SRIs) and policy review the facility failed to complete an investigation for Resident #47 and also failed to complete a thorough investigation for Resident #117 as required. This affected two (#47 and #117) of three residents reviewed for abuse. The facility census was 121.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure adequate monitoring, assessments, and wound treatments were completed as ordered. This affected one (#31) of one resident reviewed for wounds. The facility census was 121.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to implement pressure ulcer prevention interventions and treatments. This affected one (#10) of three residents reviewed for pressure ulcers. The facility census was 121.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #117 received a thorough fall investigation and failed to ensure fall interventions were in place for Resident #8. This affected two (#117 and #8) of four residents reviewed for falls. The facility census was 121.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure Resident #10's foley catheter output was monitored as ordered. This affected one (Resident #10) of three reviewed for catheters. The facility census was 121.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and the facility policy review the facility failed to ensure Resident #01's percutaneous endoscopic gastrostomy (PEG) tube dressing was in place. This affected one of one residents reviewed for PEG tube care. The facility census was 121.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure medications were administered as ordered. This affected three (#1, #4 and #47) of seven residents reviewed for medications administration. The facility census was 121.

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to ensure monthly pharmacy recommendations were completed timely and further failed to ensure the physician order for pharmacy recommendations were followed. This affected two (#4 and #6) of five residents reviewed for unnecessary medications. The facility census was 121.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free of significant medication errors. This finding affected two (Residents #85 and #141) of seven residents reviewed for medication administration. The facility census was 121.

Inspectors wroteBased on observation, record review, staff interview, review of storage information, and facility policy review, the facility failed to ensure insulin pen injectors were disposed of when expired and the facility failed to ensure medications were not left at bedside. This affected one (#85) of one resident reviewed for medications at bedside and two (#104 and #01) of two residents receiving insulin. The facility census was 121. Findings Include:1. Review of Resident #104's medical record revealed a facility admission date of 04/19/23 with the diagnosis of type II diabetes mellitus. Review of Resident #104's physician orders revealed an order for Humalog subcutaneous solution pen injector 100 units per milliliter and to give two units with meals. Observation on 03/05/2026 at 8:24 A.M. [...]

Inspectors wroteBased on observation, record review, staff interview, and facility policy review the facility failed to ensure enhanced barrier precautions (EBP) were used for Residents #01, #69, and #10. This affected three (#01, #69 and #10) of three residents reviewed for EBP. The facility census was 121.

Inspectors wroteBased on observations, medical record review, review of room temperature logs, and interview, the facility failed to ensure room temperatures and temperatures in common areas were maintained within the required range and for the comfort of residents. Room temperature monitoring revealed inappropriate room temperatures in four (rooms 147, 171, 270 and 275) of 11 resident rooms and three of seven common areas affecting seven residents (Residents #29, #40, #46, #52, #68, #72 and #73) and two unidentified residents. The census was 118. Findings Include: On 01/28/26 between 9:20 A.M. and 9:52 A.M., random room temperatures were monitored by Maintenance Technician #200, using the facility ambient thermometer. The following rooms/areas were identified to be outside the regulatory temperature ranges: (temperatures were measured in Fahrenheit)a. [...]

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure medications remained in their original labeled packaging and failed to ensure insulin pens and vials were appropriately labeled and not used past the expiration date. Improper medication storage was identified in two of four medication carts observed. This affected three residents (Residents#22, #86 and #113). The facility census was 118. Findings Include: 1. On 01/28/26 at 12:30 P.M., the Ridgeview medication cart was observed with Licensed Practical Nurse (LPN) #230. There was an unlabeled vial of open Lantus insulin. The vial was not designated as belonging to a specific resident. On 01/28/26 at 12:30 P.M., LPN #230 stated the vial of Lantus insulin had to belong to Resident #86 because he was the only resident whose medications were stored on the cart that received Lantus insulin. [...]

Inspectors wroteBased on observation, review of the medical record, interview, and review of the facility policy, the facility failed to ensure the privacy of Resident #118's medical record was maintained and failed to ensure privacy was maintained during care for Resident #54. This affected two residents (Resident #54 and #118) of five observed for privacy. Findings Include:1. Review of the medical record revealed Resident #118 was admitted to the facility on [DATE]. Diagnoses included diabetes mild cognitive impairment, hypothyroidism, hypertension, generalized anxiety disorder, dementia, personality disorder, peripheral vascular disease, and bipolar disorder. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #118 had intact cognition. Observations on 12/31/25 from 9:30 A.M. to 9:35 A.M. [...]

Inspectors wroteBased on review of the medical record, review of shower schedules, interview, and review of the facility policy, the facility failed to ensure personal bathing preferences were accommodated and showers were documented/completed for Resident #27. This affected one resident (#27) out of three residents reviewed for bathing. Findings Include:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included volvulus, urinary tract infection osteoarthritis, peripheral neuropathy, breast cancer, skin cancer, acute embolism of right lower extremity, and osteoporosis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had intact cognition and did not refuse care. She required moderate assistance with bathing. Review of the nurse's note dated 10/06/25 at 2:57 P.M. [...]

Inspectors wroteBased on medical record review, staff interview, resident interview, observation, and facility policy review, the facility failed to ensure systems were in place to provide appropriately sized incontinence products to residents, subsequently leading to Resident #79's development of moisture-associated skin damage (MASD). Additionally, the facility failed to ensure Resident #79 was comprehensively assessed after developing MASD. This affected one resident (#79) of three residents reviewed for adequate supplies. Findings Include:Review of the medical record revealed Resident #79 admitted to the facility on [DATE]. Diagnoses included displaced bimalleolar fracture of the right lower leg, chronic obstructive pulmonary disease, rheumatoid arthritis, glaucoma, congestive heart failure, atrial flutter, vertigo, tachycardia, spinal stenosis, and insomnia. [...]

Inspectors wroteBased on observation, interview, policy review and review of material safety data sheet (MSDS), the facility failed to ensure possible hazardous areas and materials were properly secure on the memory care unit. This had the potential to affect 25 residents (#2, #8, #10, #12, #16, #30, #38, #39, #40, #45, #54, #60, #64, #65, #71, #79, #87, #89, #92, #94, #100, #115, #118, #121, and #129) that were able to ambulate and propel in wheelchairs on the memory care unit. Facility census was 129.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure resident representatives received room change notification. This affected one resident (#121) of three residents reviewed for family notifications. The census was 129.

Inspectors wroteBased on record review and interviews, the facility failed to ensure Resident #81 was administered intravenous antibiotics as ordered resulting in a significant medication error. This affected one (Resident #81) out of three residents reviewed for medication administration. Facility census was 129.

Inspectors wroteBased on medical record review and interview the facility failed to timely assess and obtain necessary treatment for Resident #207 for a urinary tract infection. This affected one resident (#207) of three residents reviewed for urinary tract infection. The facility census was 127.

Inspectors wroteBased on observation, record review, facility temperature log review, policy review and interview, the facility failed to ensure the boiler systems were functional and operational for resident/staff access to adequate hot water. This had the potential to affect all 124 residents residing in the facility. Findings Include: Review of facility concern logs for [DATE] revealed there was a concern with hot water running and resolution of repairs being made. In [DATE] there was a concern of water temperatures being Lukewarm. Interview on [DATE] at 6:39 A.M. with Certified Nursing Assistant (CNA) #378 revealed there had been no hot water on the memory care unit for the past couple weeks. CNA #378 reported this had affected the staff ability to assist with showers. Observation on [DATE] from 6:52 A.M. to 7:03 A.M. [...]

Inspectors wroteBased on observation, record review, facility temperature log review, policy review and interview, the facility failed to ensure a clean, comfortable and homelike environment. The facility failed to ensure water temperatures were maintained at a comfortable level for resident bathing/showers, failed to maintain an adequate supply of clean bath linens for resident use and failed to ensure garbage bags were available and provided in resident rooms to contain trash. This affected 11 residents (#3, #20, #27, #30, #32, #44, #96, #100, #111, #113 and #124) reviewed for water temperatures, one resident (#40) reviewed for linen availability with the potential to affected an additional undetermined number of residents based on staff interview and four residents (#32, #40, #44, and #48) reviewed for garbage disposal. The facility census was 124.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure care plans were comprehensive. This affected three residents (Resident #62, #93, and #125) of 10 residents reviewed for care plans. Facility census was 124.

Inspectors wroteBased on record reviews, care conference postcard and letter invitation review, interviews and policy review the facility failed to ensure care plan meetings were offered timely, per preference, and in person. This affected one (Resident #40) of three residents reviewed for care plan meetings. The facility census was 124.

Inspectors wroteBased on interviews and closed medical record review, the facility failed to ensure physician orders were followed and the physician was contacted with elevated blood pressure findings. This affected one resident (125). The facility census was 124.

Inspectors wroteBased on observation, interviews and policy review, the facility failed to ensure meals were served timely on the Memory Care Unit. This affected all 33 residents residing on the Memory Care Units (Resident #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, and #51). The facility Census was 124.

Inspectors wroteBased on observation, interview and record review the facility failed to implement infection control procedures during medication administration. This affected one resident (#100) of five residents observed for medication administration. The facility census was 124.

Inspectors wroteBased on observation of facility recorded video footage with sound, observation of police officer body camera footage, medical record review, facility incident review, review of a self-reported incident, interview, dementia training curriculum review, facility assessment review and policy review the facility failed to ensure Resident #145, who was cognitively impaired and had a diagnosis of dementia, was provided adequate, necessary kind, appropriate and dignified dementia care to meet his total care needs. This resulted in immediate jeopardy and the potential for serious harm and injury on 07/06/25 at 5:46 A.M. when the resident began to wander throughout the facility secured dementia unit. [...]

Inspectors wroteBased on observation, record review, policy review, and interviews, the facility failed to implement a comprehensive and resident centered plan to prevent and/or treat the development of pressure ulcers. Actual harm occurred beginning on 06/08/25 when Resident #95, who was at high risk for pressure ulcer development and dependent on staff for activities of daily living, developed an avoidable Stage II pressure ulcer (partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose [fat] is not visible, and deeper tissues are not visible. Granulation tissue, slough and eschar are not present) to the left buttock. [...]

Inspectors wroteBased on interviews, record reviews, policy review, and staffing schedules, the facility failed to ensure they were adequately staffed to ensure Residents ( #7, #9, #14, #17, #20, #22, #23, #24, #25, #26, #28, #29, #32, #33, #37, #38, #41, #44, #50, #51, #52, #59, #62, #66, #73, #74, #75, #77, #89, #92, #95, #96, #100, #110, #115, #122, #125, #126, #127, #135, #139, and #145) were adequately supervised, provided incontinence care, had medications administered as ordered, had treatments completed as ordered, and received meal trays. This affected 42 Residents( #7, #9, #14, #17, #20, #22, #23, #24, #25, #26, #28, #29, #32, #33, #37, #38, #41, #44, #50, #51, #52, #59, #62, #66, #73, #74, #75, #77, #89, #92, #95, #96, #100, #110, #115, #122, #125, #126, #127, #135, #139, and #145) out of 141 residents. However, this had the potential to affect all residents. The facility census was 141.

Inspectors wroteBased on medical record review, resident interview, and test tray results, the facility failed to maintain palatable and appetizing food temperatures. This had the potential to affect all but two residents ( Resident #68 and Resident #66) who did not receive a meal tray from the kitchen. The census was 144.

Inspectors wroteBased on observation, record review, policy review, review of facility billing/financial information, review of the facility assessment, review of the Administrator's job description, and interviews the facility failed to ensure effective and efficient administration to meet the total care needs of all residents in the facility. The facility census was 141.

Inspectors wroteBased on Record review, facility policy review, facility assessment, and interviews , the facility failed to ensure an effective governing body, legally responsible for establishing and implementing policies regarding the management and operation of the facility, including but not limited to compliance with all financial obligations for the delivery of care. This had the potential to affect all 141 residents in the facility.

Inspectors wroteBased on observation, medical record review, interviews and facility policy review, the facility failed to maintain a sanitary and homelike environment. This affected three residents (Resident #11, #53 and #65) but had the potential to affect all 141 residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications were secure on the memory care unit. This had the potential to affect all 35 residents on the memory care unit. The facility census was 141.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident #37 was provided with a diet texture as ordered. This had the potential to affect eight residents ( Resident #34, #81, #95, #97, #98, #101, #134, and #135) who received puree diets. The facility census was 141.

Inspectors wroteBased on interviews, facility email, medical record review, and policy review, the facility failed to ensure Resident #26 was treated with dignity and respect. This affected one (Resident #26) out of three residents reviewed for dignity and respect. The facility census was 141.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents had access to funds in a reasonable amount of time. This affected four residents ( Resident #139, #38, #22, and #85) of four residents reviewed for resident funds. The facility managed 40 resident fund accounts. The facility census was 141.

Inspectors wroteBased on record review and interview, the facility failed to honor Resident #145's power-of-attorney (POA) request for Depakote (mood stabilizer) to be held. This affected one (Resident #145) out of three residents reviewed for choices. The facility census was 141.

Inspectors wroteBased on record review and interview, the facility failed to notify Resident #145's family and physician in a timely manner of changes in behavior and medications. This affected one (Resident #145) out of three reviewed for notifications. Facility census was 141.

Inspectors wroteBased on medical record review, staff interview, facility investigation, self-reported incident (SRI), and policy review, the facility failed to complete a thorough and adequate investigation in a timely manner. This affected one (Resident #145) out of two reviewed for abuse. The facility census was 141.

Inspectors wroteBased on record review and interview, the facility failed to ensure an assessment was completed before Resident #145 was placed on the secure/memory care unit. This affected one (Resident #145) out of three reviewed for placement on the secure unit. The facility census was 141.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #145 had an individualized care plan in place to address behaviors. This affected one (Resident #145) out of three residents reviewed for care plans. The facility census was 141.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to provide residents who were dependent with bathing, two showers a week. This affected one (Resident #77) out of three reviewed for activities of daily living (ADL). The facility census was 141.

Inspectors wroteBased on obervation, review of video and photographic images, review of the facility assessment, review of the facility admission agreement, review of utility bills, review of vendor/supplier invoices, interview with staff, residents, facility vendors and medical supply companies and utility company representatives, the facility failed to effectively manage financial obligations required to secure the necessary resources required to ensure the ongoing appropriate delivery of care to meet the needs of the residents resulting in potential situations of resident neglect. This had the potential to affect all 132 residents residing in the facility.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure care plans were comprehensive for Residents #102 and #122. This affected two residents (#102 and #122) of six residents whose care plans were reviewed. The facility census was 132.

Inspectors wroteBased on review of medical records, interviews, review of the shower schedule, and review of facility policy, the facility failed to provide assistance with bathing services as scheduled to Residents #67 and #102. This affected two residents (#67 and #102) of three residents who were reviewed for assistance with activities of daily living (ADL). The facility census was 132.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to maintain a clean and sanitary environment. This affected 33 residents (#2, #5, #6, #15, #20, #28, #34, #37, #38, #39, #41, #47, #51, #52, #53, #56, #68, #73, #74, #78, #79, #80, #86, #92, #95, #98, #116, #118, #119, #120, #122, #124 and #125) on the memory care unit and had the potential to affect all 132 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure staffing information was posted timely. This had the potential to affect all 132 residents in the facility.

Inspectors wroteBased on medical record review and staff interview the facility failed to transfer residents appropriately using a mechanical lift resulting in a fall. This affected one (Resident #19) of three residents reviewed for falls. The facility census was 145.

Inspectors wroteBased on observation, review of the medical record, and interview, the facility failed to timely identify areas of new skin impairment for Resident #39. This affected one resident (Resident #39) of one reviewed for pressure ulcers. Actual harm occurred on 01/03/23 when Resident #39, who was cognitively impaired, at high risk for pressure ulcer development, and dependent on staff for bed mobility, was found to have a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) with a necrotic area to the left heel.

Inspectors wroteBased on observations, review of the medical record, and interviews the facility failed to ensure fingernails were cleaned and trimmed for dependent Residents #13, #54, and #63 and failed to ensure showers were completed as scheduled for dependent Residents #41 and #45. This affected five residents ( Resident #13, #41, #45, #54, and #63) of seven reviewed for activities of daily living (ADLs).

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure resident representatives were notified of a resident with significant weight loss. This affected one (Resident #70) of three residents reviewed for weight loss. The facility census was 108.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure fall risk assessments were completed for two (Resident #29 and Resident #34) of five residents reviewed for falls. The facility census was 108.

Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to ensure antibiotic assessments were completed prior to initiation of antibiotic medication to determine appropriate use and indication of antibiotic medication. This affected one (Resident #56) of six residents reviewed for antibiotic medication use. The facility census was 108.

Inspectors wroteBased on review of the medical record, resident interviews and staff interviews the facility failed to ensure Resident #44 and Resident #51 received COVID-19 vaccine education. This affected two residents (Resident #44 and #51) of five reviewed for COVID-19 vaccinations.

Inspectors wroteBased on personnel record review and staff interview, the facility failed to complete annual State Tested Nurse Assistant (STNA) performance evaluations as required. This affected three STNA's (STNA #247, STNA #259, and STNA #263) of three STNA's reviewed for annual performance evaluations and had the potential to affect all residents receiving care in the facility.

Inspectors wroteBased on observation, interview and facility policy and procedure, the facility failed to properly store medications in the Greenbrier medication cart (serving Residents #8, #10, #18, #33, #36, #39, #44, #55, #67, #100, #101, #110, #112, #113, #144, #390, and #391) cart and the Ridgeview medication cart (serving Residents #7, #15, #20, #43, #48, #49, #53, #58, #60, #61, #62, #71, #72, #74, #76, #90, #93, #120, #122, and #439) and the facility failed to properly dispose of medications on the dementia unit. These concerns had the potential to affect all 37 residents receiving medications from the two medication carts and had the potential to affect 10 residents (#11, #18, 44, #45, #67, #84, #109, #111, #241, #391) who were mobile in the dementia unit dining room out of 37 residents on the dementia unit. The census was 136.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure servings were appropriate, food was palatable, and food was served at appropriate holding temperatures. This had the potential to affect 37 residents (Resident #4, #13, #15, #20, #21, #25,#28, #29, #40, #49, #53, #56, #58, #60, #64, #73, #74, #82, #86, #87, #88, #89, #91, #93, #98, #99, #118, #121, #123, #125, #126, #127, #130, #132, #136, #339, and #439) of 84 residents who reside on the second floor and eat meals served from the kitchenettes and affected Resident #15, #20, #28, #60, #93 and #118 and had the potential to affect the other 42 residents (Residents #5, #7, #8, #9, #10, #11, #12, #18, #24, #30, #33, #35, #38, #41, #44, #49, #51, #53, #57, #63, #67, #79, #81, #84, #85, #91, #98, #99, #102, #104, #108, #112, #113, #114, #120, #123, #127, #129, #135, #136, #391, and #439) who received a regular [...]

Inspectors wroteBased on record review and interview the facility failed to ensure Advanced Directives, directions for desired care in the event of cardiac or respiratory arrest, were clear and accurate for Resident #32. This affected one of one resident reviewed for Advanced Directives. The facilities census was 136.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure residents using a Broda chair were assessed to determine if the chair was being used as a possible restraint prior to implementation. This affected one (Resident #59) of one residents reviewed for restraint use.

Inspectors wroteBased on record review and interview the facility failed to accurately screen Resident #46 via the pre-admission screening and resident review (PASARR) to determine necessary care and services. This affected one resident of one resident reviewed for PASARR. The facility's census was 136.

Inspectors wroteBased on medical record review, observation and interview the facility failed to ensure Resident #32 had her geri- sleeves applied per physician order. This affected one resident out of one reviewed for adaptive equipment. The facility census was 136.

Inspectors wroteBased on observation, record review, and interview the facility failed to conduct a safe Hoyer (mechanical) lift transfer for Resident #48. This affected one of five residents reviewed for accidents. The census was 136.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Resident #137 had orders in place for staff to provide routine care and cleaning for his indwelling urinary catheter. This affected one of one resident reviewed for urinary catheters.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure two residents were free from unnecessary medications. This affected two (Resident #24 and Resident #82) out of six residents reviewed for unnecessary medications. The census was 136.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow proper infection control measures during incontinence care for Resident #37 and with a dressing care for Resident #95. This affected two (Resident #37 and Resident #95) out of two residents during random infection control observations. The census was 136.