St. Luke Lutheran Nursing Home

Inspectors wroteBased on observations, clinical record review, facility policy review and staff interviews the facility failed to ensure residents needing a mechanical lift were provided safe and appropriate transfers to prevent injuries for 1 of 1 residents reviewed (Resident #54). This failure resulted in the resident falling out of the mechanical lift during a transfer and obtaining injuries and therefore causing an Immediate Jeopardy to the health, safety, and security of the residents. The facility failed to prevent further falls by following the care plan and implemented interventions for 1 of 1 residents reviewed (Resident #70). [...]

Inspectors wroteBased on observation, resident interviews, and staff interviews the facility failed to respect each resident's dignity throughout all care and services provided to 6 out of 22 residents reviewed (Resident #5, #44, #54, and #80 ). The facility reported a census of 68 residents.

Inspectors wroteBased on personnel file review, facility policy review and staff interview the facility failed to meet requirements for Dependent Adult Abuse Mandatory Reporter Training for 1 of 5 employees reviewed (Staff H). The facility identified a census of 68 residents.

Inspectors wroteBased on clinical record review, observation, staff interview and facility policy review the facility failed to provide privacy of a body during personal cares (Resident #11 and #54). The facility reported a census of 27 residents.

Inspectors wroteBased on clinical record review, observations, facility policy review and staff interviews the facility failed to protect residents from the use of physical restraint that the resident could not remove on their own (Resident #54). The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 4 of 4 residents reviewed for abuse (Resident #5, #44, #54, and #80). The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notices were signed by the residents and or the resident's responsible person when residents transferred out of the facility. The chart also lacked documentation regarding notification and residents or resident's responsible person's decision to enact a bed hold for 2 of 2 residents reviewed (Residents #3 and #23). The facility reported a census of 68 residents.

Inspectors wroteBased on clinical record review, staff interviews and the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately document and submit an accurate resident Minimum Data Set (MDS) Assessment for 2 of 3 residents reviewed (Resident #6 and #10). The facility reported a census of 68 residents.

Inspectors wroteBased on observation, infection control policy and staff interview, the facility failed to wear Enhanced Barrier Precautions (EBP) with catheter care and failed to perform hand hygiene between glove changes with 1 of 1 residents (Resident #41). The facility reported a total census of 68 residents.

Inspectors wroteBased on observation, interviews, video and record review, the facility failed to account for the whereabouts of 1 of 1 resident reviewed (Resident #16), and failed to ensure that the door alarms were activated. The facility failed to transfer correctly 1 of 1 resident reviewed for a transfer with a sit to stand lift, (Resident #23). On the evening of 5/7/24, Resident #16 used the handicap button, that did not trigger an alarm, to exit through the front door at 7:20 PM. A staff member from the assisted living facility returned him to the nursing home at 10:10 PM. Nursing home staff were unaware that he had been gone for over 2 hours and that he had fallen during his time outside. Staff later found that the alarm to the front door had been turned off earlier that evening. This failure caused an Immediate Jeopardy to the health, safety and security of the residents. [...]

Inspectors wroteBased on record review, interview and policy review the facility failed to obtain complete resident records. A facility form titled: Authorization for Withholding CPR (Cardiopulmonary Resuscitation) did not include a date, or physician signature and/or a witness signature for 4 of 27 reviewed, (Residents #3, #23, #2 and #121) . The facility reported a census of 67 residents.

Inspectors wroteBased on clinical record review, observations, resident interviews, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 4 of 4 residents reviewed (Residents #11, #21, #33, and #41) requiring the use of oxygen. The facility reported a census of 67 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during resident cares (Resident #21, Resident #64). The facility further failed to diminish the risk of spreading SARS-CoV-2 (COVID-19) during an active outbreak. The facility reported a census of 67. 1. The MDS assessment dated [DATE], documented Resident #21 had a BIMS score of 12/15 indicating moderate cognitive impairment. The MDS documented diagnoses that included coronary artery disease (CAD), heart failure, neurogenic bladder, and benign prostatic hyperplasia. The assessment section entitled Functional Abilities and Goals (GG) revealed Resident #21 required extensive assistance to dependent assistance with activities of daily living (ADLs), mobility and transfers. [...]

Inspectors wroteBased on observations, interviews, clinical record review, and facility policy, the facility failed to provide dignity by consistently knocking on residents ' doors before entering. The facility reported a census of 67 residents. Findings Include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #4 scored 14/15 on the Brief Interview for Mental Status (BIMS) indicating the resident is cognitively intact. Resident #4 on 8/19/24 at 1:50 PM stated staff do not knock prior to entering her room or announce themselves. The resident stated staff just walk in, do whatever they want, and give orders. Continuous observation on 8/20/24 at 9:49 AM identified Staff H, Certified Nursing Assistant (CNA), Staff I, CNA/Certified Medication Aide (CMA), and Staff J, CNA, delivering towels. [...]

Inspectors wroteBased on observations, staff interview, clinical record review, and policy review the facility failed to review and revise the care plan for 1 of 24 residents reviewed (Resident #30). The facility reported a census of 67 residents.

Inspectors wroteBased on observation, interviews and record review the facility failed to follow the interventions and physicians' orders to prevent worsening of pressure ulcers for 2 of 3 residents reviewed, (Residents #64 and #30). Resident #64 had a treatment order for a chronic heel ulcer and the treatment was not followed. Resident #30 had an order to place boots on both feet to prevent worsening of ulcers. Staff were applying a boot to the right foot only. The facility reported a census of 67 residents.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure call lights were answered in under 15 minutes for 4 out of 4 residents reviewed (Resident #2, #5, #6 and #7). The facility reported a census of 75 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy reviews the facility failed to ensure food was covered before leaving the dining area and served to residents in their rooms. The facility identified a census of 75 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility record review, the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals (DIA) within 24 hours for 1 of 1 residents reviewed for abuse (Resident #5). The facility reported a census of 75 residents.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review the facility failed to investigate allegations of abuse and separate resident from staff alleged of abuse during the investigation for 1 of 1 resident reviewed (Resident #5). The facility reported a census of 75 residents.

Inspectors wroteBased on resident and staff interview, record review, and policy review the facility failed to follow a physician's order for one of twelve residents reviewed, (Resident #2). The facility reported a census of 62 residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide care in a manner to assure cleanliness and prevent infection for 1 of 2 residents with a catheter (Resident #112). The facility reported a census of 62 residents.

Inspectors wroteBased on resident, staff and record review, the facility failed to ensure staff answered resident call lights and responded to resident needs in a timely manner, within fifteen minutes, for 3 out of 20 residents interviewed (Residents #13, #5, and #37). The facility reported a census of 61 residents.

Inspectors wroteBased on observation, resident and staff interview, and policy review the facility failed to serve food and drink at a safe and appetizing temperature. The facility reported a census of 62 residents.