Lutheran Home

In the surveyor’s words

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

• Actual harm, isolatedF697Jan 31, 2022

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure appropriate care and services were provided and physicians orders were followed to ensure one resident's (Resident #89) pain was addressed. Actual Harm occurred on 12/31/21 at 6:00 P.M. when Resident #89 was admitted to the facility from the hospital following surgery of a right above the knee amputation, the physician orders were not followed for pain medication, and Resident #89 had to be transported back to the hospital emergency department on 12/31/21 at 10:10 P.M. by Emergency Medical Services (EMS) for control of severe pain. This affected one out of three residents reviewed for pain. […]

• No harm, potential for more than minimal, widespreadF919Jan 31, 2022

  Based on observation, interview, record review, and facility policy review, the facility failed to consistently provide a functioning call light system to ensure care and services were provided for the residents. This had the potential to affect all the residents residing in the facility. The facility census was 98. Findings include: Interview on 01/25/22 at 11:39 A.M. with Resident #31 revealed the call light system did not work correctly. Resident #31 stated she would activate her call light and no staff would come to assist her. Observation of Resident #31 revealed she pressed her call light for staff assistance and no nurse or State tested Nursing Assistant (STNA) entered the room to answer the call light. Observation on 01/25/22 at 11:50 A.M. […]

• No harm, potential for more than minimal, widespreadF880Oct 12, 2021

  Based on observation, interview, and review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP), and review of the CDC Covid Tracker data, the facility failed to maintain proper infection control procedures to prevent the potential spread of Covid-19. This had the potential to affect all residents residing in the facility. The census was 91. Findings include: Observation on 10/07/21 at 5:06 A.M. revealed Licensed Practical Nurse (LPN) #201 exiting a resident's room without a face mask or eye protection. LPN #201 quickly began looking for a mask and eye protection and stated she had misplaced her face mask and eye protection and was unable to locate it. […]

• No harm, potential for more than minimal, patternF677Aug 17, 2022

  Based on observation, interview, record review and review of the facility policy, the facility failed to provide scheduled showers for three residents, Resident #301, #302, and #303 and the facility failed to provide personal hygiene, shaving and grooming, for two residents, Resident #301 and #302 of three residents reviewed. The facility census was 106. Findings include: 1. Record review for Resident #303 revealed an admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #303 was rarely or never understood. Resident #303's long term memory was ok. Resident #303 had short term memory problems. […]

• No harm, potential for more than minimal, patternF684Aug 17, 2022

  Based on record review and interview, the facility failed to answer call lights for residents requiring assistance in a timely manner. This had the potential to affect all residents who activated their call lights for assistants. The facility census was 106. Findings include: Interviews on 08/15/22 from 10:10 A.M. through 12:43 P.M. with Resident #301, #302, #304, #305, #308, #309, #311, and #312 revealed call lights were not answered timely and at times took one to two hours to answer. Interviews on 08/15/22 between 10:28 A.M. and 08/17/22 at 12:46 P.M. […]