Lutheran Convalescent Home

In the surveyor’s words

From the most serious findings on record at Lutheran Convalescent Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF759Nov 7, 2024

  Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 27 opportunities observed, four errors occurred resulting in a 14.81% error rate (Residents #31, #10, #12 and #88). The census was 123 with 99 residents in certified beds. Review of the facility's Administering Medications policy, review date 1/30/24, showed: -Purpose: Medication shall be administered in a safe and timely manner and as prescribed. The community shall provide resident with the necessary medication(s) when they leave the community temporarily; -Policy Interpretation and Implementation: 1. Medications must be administered in accordance with the orders, including any required time frame. 2. […]

• No harm, potential for more than minimal, patternF812Nov 7, 2024

  Based on observation, interview and record review, the facility failed to ensure dietary staff used proper hand hygiene during meal service and failed to ensure the kitchen ceiling was free from dust accumulation. The sample was 20. The census was 123 with 99 residents in certified beds. Review of the facility's hygiene and sanitary practices policy, revised 2/16/24, showed: -Policy statement: Dining services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; -Policy implementation: Employees must wash their hands after personal body functions, after using tobacco, eating or drinking, whenever entering or re-entering the kitchen; before coming in contact with any food surfaces, after handling raw meat, poultry or fish and when… […]

• No harm, potential for more than minimal, patternF880Nov 7, 2024

  Based on observation, interview, and record review the facility failed to follow enhanced barrier precautions (EBPs) to prevent risks of infection for three of 20 sampled residents (Residents #29, #40, and #74) and failed to provide direct care following acceptable infection control procedures for another resident (Resident #39). This failure had the potential to affect all residents in the facility. The census was 123 with 99 residents in certified beds. Review of the facility's Enhanced Barrier Precautions policy, revised on 4/9/24, showed: -Enhanced barrier precautions are used as an infection prevention control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents; -EBPs employ targeted gown and glove use during high contact resident care activities… […]

• No harm, potential for more than minimal, patternF812Aug 10, 2023

  Based on observations, interviews, facility document and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to label and date perishable and non-perishable food items in 1 of 2 walk-in refrigerators, 1 of 3 walk-in freezers, and 1 of 1 dry storage area. The facility also failed to label and date perishable items in the refrigerators and freezers in 2 out of 8 satellite unit kitchens. Findings included: Review of a facility policy titled, Food Flow-Storage, revised on 11/01/2023, revealed, Discard ready-to-eat foods that are not date marked or that exceed the 4-day time period. […]

• No harm, potential for more than minimal, isolatedF744Aug 12, 2026

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) with a diagnosis of dementia received appropriate treatment and services to attain or maintain his/her highest psychosocial well-being. The sample size was three. The census was 130. The administrator was notified on 08/12/26, of the past non-compliance. The facility responded appropriately when the incident occurred. Certified Nursing Assistant (CNA) A was suspended pending an investigation and then terminated. The facility provided training and in-services for all staff regarding abuse and neglect. The deficiency was corrected on 08/11/26. […]