Grace Lutheran Communities - River Pines

In the surveyor’s words

From the most serious findings on record at Grace Lutheran Communities - River Pines, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Feb 26, 2025

  Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice has potential to affect all 46 residents residing in the facility. The facility's Dietary Manager (DM) has been in the position for over 2 years, had enrolled in a course in 8/2022, but did not complete the steps to become certified. The facility does not have a full-time Registered Dietician (RD) at the facility. Findings include: On 2/25/25, at 7:57 AM, Surveyor interviewed Dietary Manager (DM) E. DM E reported that she became the Dietary Manager 2 years ago. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 2025

  Based on interview, record review, and observation, the facility failed to implement correct monitoring of the dish washer for sanitization purposes. This has the potential to affect all 46 residents residing in the facility. The facility did not ensure facility protocol was followed to ensure safe sanitization of dishware via their dishwasher. Findings include: The facility protocol on log sheet: Report if wash Temperature is Less than 110 Report if rinse temp is 120 Report if test strip does not reach between 50-100ppm (parts per million) The Association of Nutrition and Foodservice Professional titled, Know Your Sanitizer states, .If PPM sanitizer solution is too high, it can be considered unsafe and ineffective, potentially leaving harmful chemical residues on surfaces and posing a… […]

• No harm, potential for more than minimal, isolatedF628May 21, 2026

  Based on interview and record review, the facility did not ensure that appropriate information is communicated to the receiving health care institution or provider for 1 of 1 resident (R22) reviewed for hospitalizations.Facility did not communicate with the hospital emergency department (ED) prior to R22's transfer of the reason R22 needed to be transferred. This is evidenced by:On 05/20/26, Surveyor reviewed R22's medical record. R22's diagnoses include displaced trimalleolar fracture of right lower leg, anemia, congestive heart failure, mild cognitive impairment, COPD, chronic kidney disease stage 3B, restless legs, depression, type 2 diabetes mellitus, and dementia.R22's progress notes documented 05/03/2026 9:25 PM, Health Status Note,Note Text: Pt transferred to ED for evaluation after… […]

• No harm, potential for more than minimal, isolatedF684May 21, 2026

  Based on interview and record review, the facility did not ensure 3 of 5 (R22, R3 and R4) sampled residents received care and treatment in accordance with assessments and professional standards of practice to ensure their highest practicable physical, mental, and psychosocial well-being. The facility staff did not complete a full assessment when changes in condition occurred, did not assess upon re-admission, and did not coordinate care plans with hospice to ensure consistency and continuity of care. On 05/03/26, the facility did not complete and document a full assessment of R22's change of condition and on 05/04/26 did not complete and document a re-admission assessment. The facility did not coordinate R3's care plans with hospice to ensure consistency and continuity of care. […]

• No harm, potential for more than minimal, isolatedF688Feb 26, 2025

  Based on interviews and record review, the facility did not ensure residents with limited range of motion (ROM) received services to maintain or prevent further reduction in ROM for 1 out of 2 residents (R) (R30). R30's restorative care plan from therapy on 1/24/2025 was not implemented. R30's restorative care plan from therapy on 7/1/2024 was not being followed. Findings include: R30 admitted to the facility on [DATE] with diagnoses to include post polio syndrome, osteoarthritis, and pain in right shoulder. R30's quarterly Minimum Data Set (MDS) assessment dated , 2/7/2025, indicated R30 had no impairment in ROM in both upper extremities and impairment on both lower extremities. R30 needed maximum assist in multiple areas of mobility. […]