St. John's Lutheran Home

Inspectors wroteBased on interview and record review, the facility nursing staff failed to meet professional standards of quality by not ensuring all controlled substance medications were accurately accounted for and documented in a resident's EHR, for 3 (#s 2, 6, and 9) of 3 sampled residents for controlled substance medications. This deficient practice affected the accuracy of medication administration records, had the potential to result in administration errors, and to allow unidentified controlled substance diversion to occur.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right to a dignified existence for 1 (#8) of 3 sampled residents. The failure exposed the resident to feelings of embarrassment and shame associated with incontinence.

Inspectors wroteBased on interview and record review, the facility violated a resident's right to privacy during incontinence care when, during direct care and in the presence of the resident, a caregiver used her personal cell phone to discuss a resident's care with someone who was not a staff member of the facility for 1 (#7) of 3 residents sampled for abuse by facility staff. The failure involved allowing an unauthorized person, not employed by the facility, to be present via telephone during incontinence care.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by a staff member for 1 (#7) of 3 residents sampled for abuse by facility staff. During the survey, it was found the facility had previously identified, investigated, and corrected the non-compliance for abuse by a staff member.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident from misappropriation of resident property in the form of missing medication for 1 (#9) of 3 sampled residents. The failure increased the risk of the resident not having enough medication to adequately manage her anxiety.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident abuse in a timely manner for 1 (#8) of 5 residents sampled for timeliness of reporting abuse allegations.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a system that accurately recorded, monitored, and reconciled the accuracy of dispensing lorazepam oral liquid for 1 (#9) of 3 sampled residents for use of controlled substance medications. The deficient practice resulted in a discrepancy between the number of doses removed from secure storage and the number of doses administered to a resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired foods; failed to ensure dietary staff prepared and served food in a sanitary manner; and failed to properly test dish sanitization water used to sanitize dishes in the kitchen. This deficient practice had the potential to affect all residents served food in the LTC Cottages by increasing the risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used appropriate hand hygiene after assisting residents; failed to ensure staff used appropriate hand hygiene while preparing ready-to-eat foods; and failed to ensure enhanced barrier precautions were followed for 1 (#4) of 25 sampled residents. This deficient practice increased the spread of bacteria and increased the risk of infections to residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a facility policy and procedure for written grievances to be submitted anonymously; failed to provide residents with readily available grievance forms; and failed to provide a resident with the option to submit written grievances anonymously for 1 (#83) of 25 sampled residents. This deficient practice could affect all residents residing in the [NAME] cottage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan, for a resident who required oxygen therapy for 1 (#12) of 25 sampled residents. The facility's failure could jeopardize the resident's health resulting in a risk for low blood oxygen levels or oxygen services not being provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident-centered care plan was updated to include specific activity preferences and current participation for 2 (#s 24 and 56); and include use of enhanced barrier precautions for 1 with an indwelling urinary catheter (#9) of 25 sampled residents. This deficient practice increased the risk of staff members not implementing resident-centered care plans in the specific areas of activities and infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent, for 2 (#s 35 and 77) of 25 sampled residents. The medication error rate was calculated as 5.41 percent, and the medication errors placed the residents at increased risk of negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to report their investigative findings of a facility reported incident to the State Survey Agency in a timely manner for 2 (#s 23 and 72); and failed to report allegations of resident abuse to the State Survey Agency within 24 hours of the incident for 2 (#s 24 and 95) of 25 sampled residents. This deficient practice increased the risk of unnecessary psychosocial harm to the residents involved in the incident due to the delay in reporting both the allegations of resident abuse and results of the facility investigation.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were served meals to meet their nutritional needs, and staff serving meals failed to use the menu's and serve the planned meal, or offer an appropriate substitute, for the residents in the [NAME] Cottage.

Inspectors wroteBased on observation, interview and record review, the facility failed to update the comprehensive care plan for a resident who was dealing with grief, for 1 (#41); failed to update the care plan of a resident with frequent falls for 1 (#47); and failed to update the care plan of a resident who no longer had adjustment issues for a room change which occurred more than 12 months prior for 1 (#3) of 26 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to post daily staffing in the four cottages which housed 51 longterm care residents. Failing to post the daily staffing would not allow anyone wishing to view the informaton, such as residents, staff, or visitors.

Inspectors wroteBased on observation, interview, and record review, the dietary department failed to provide each resident with a nourishing diet and failed to follow the resident's therapeutic diet to meet the resident's daily needs. These deficient practices increased the risk of the [NAME] Cottage residents having negative nutritional or health outcomes, and affect their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were sufficient staff with the necessary competencies and skillsets to carry out the functions of the food and nutritive services. This deficient practice increased the risk of negative outcomes, and the quality of life and health, for the residents residing in the [NAME] and [NAME] Cottages.

Inspectors wroteBased on interview, record review, and observations, the facility failed to provide each resident with food that accommodated the resident allergies and preferences for the residents in the [NAME] Cottage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchens. This deficient practice had the potential to affect all residents who received food from the kitchen in the Powers, [NAME], and [NAME] Cottages.

Inspectors wroteBased on observation and interview the facility failed to ensure infection contol practices were followed and the staff used appropriate PPE when the facility was in COVID-19 outbreak status. These deficient practices affected residents in the [NAME] Cottage (sanitary conditions) and the [NAME] Cottage (appropriate PPE).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed for the ability to self-administer medications prior to leaving a resident unattended while taking medications for 2 (#s 3 and 10) for 26 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident neglect within 24 hours of the incident, for 1 (#77) of 26 sampled residents for abuse reporting.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Quarterly resident assessment for 1 (#3) of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan to address resident care needs, for 2 (#s 78 and 143) of 26 sampled residents.

Inspectors wroteBased on interview and record review, the facility nursing staff failed to assess and document the condition of a resident's skin as part of preventative skin care, for 1 (#3) of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to sufficiently address repeated falls for a resident who had frequent falls, and staff failed to identify root causes for the repeated falls so they could attempt to prevent future falls, failed to evaluate the effectiveness of current interventions utilized at the time of a fall for potential modification related to the fall cause, and failed to show the care plan was used effectively and reviewed, updated, or modified for the ongoing falls, and prevention of future falls, for 1 (#47) of 26 sampled residents. The deficient practice continually increased the risk of injury and or ongoing falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to help obtain mental health services for a resident who was dealing with grief and the loss of his spouse for almost a year, for 1 (#41) of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medications in a timely manner for 1 (#41) of 26 sampled residents, and the medications were provided late.

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed psychotropic medications were limited to 14 days or had documented rationale for extended use by the physician, for 2 (#s 38 and 131) of 26 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain a signed consent for administration of a pneumococcal vaccine for 1 (#58) of 26 sampled residents.

Inspectors wroteBased in interview and record review, the facility failed to ensure the process for entering and confirming medication orders was followed resulting in an incorrect dose being administered for 27 days for 1 (#1) of 3 sampled residents. The medication was an antiepileptic medication used for the control of behaviors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently monitor and maintain refrigerated food temperatures at safe levels, causing an elevated risk for foodborne illness in [Cottage Name]. This failure had the potential to affect all residents in [Cottage Name].

Inspectors wroteBased on interview and record review, the facility failed to address a resident's preference for female caregivers, for personal cares, for 1 (#4) of 6 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive resident-centered care plan for a resident with dementia with behaviors, for 1 (#1), and failed to identify, document, and utilize behavioral interventions for a resident who exhibited behaviors, and who was prescribed an antipsychotic medication to treat the behaviors, for 1 (#24) of 6 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to perform a skin assessment on a resident's sacrum for two weeks for 1 (#34) of 2 sampled residents. This deficient practice resulted in the evolution of an existing pressure ulcer from intact skin with no open areas, to open exposed tissue.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure 1 (#142) of 1 sampled resident was provided with durable medical equipment necessary to prevent adverse sleep events at night.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt, document, or care plan nonpharmacological interventions for a resident's disruptive behaviors and agitation, prior to the initiation of an antipsychotic medication, for 1 (#24) of 2 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order for antibiotics contained all necessary elements, specifically the duration of the antibiotic medication, for 1 (#59) of 3 sampled residents. The deficient practice resulted in the resident receiving five more doses than the provider ordered.