Lutheran Nursing Home

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Apr 13, 2022

  Based on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. […]

• No harm, potential for more than minimal, widespreadF885Apr 13, 2022

  Based on interview and record review, the facility failed to ensure residents and/or family were notified when a staff or resident in the facility tested positive for COVID (a new disease caused by a novel (new) coronavirus) for five sampled residents (Residents #3, #16, #39, #47, and #50) out of 15 sampled residents. The facility census was 58 residents. A policy for notification of residents and family for positive COVID staff and/or residents was requested but not received at the time of exit. 1. […]

• No harm, potential for more than minimal, patternF607Aug 1, 2025

  Based on interview and record review, the facility failed to conduct quarterly Criminal Background Checks for eight out of 10 sampled employees (Employees AA, BB, CC, DD, EE, FF, GG and HH). The facility census was 70 residents. Review of the facility Background Screening Investigations policy dated 8/23/24 showed: -The Employee Disqualifications List (EDL) is maintained through the Department of Health and Senior Services (DHSS).-The EDL is checked prior to date of hire and quarterly thereafter.1. Review of Employee AA's personnel record showed:-His/her hire date was 1/13/25.-His/her EDL check date was 1/13/25.-His/her quarterly EDL checks were due in April 2025 and July 2025 and were not completed.2. […]

• No harm, potential for more than minimal, patternF550May 6, 2024

  Based on interview, and record review, the facility failed to ensure three sampled residents (Resident #1, Resident #3, and Resident #4) were treated with dignity and self-determination related to their bathing/showering preferences out of five sampled residents. The facility census was 62 residents. Review of the facility's undated policy titled Bathing Policy showed: -It was the responsibility of the licensed nurse and/or nursing assistants to ensure baths/showers were completed. -Residents would receive a whirlpool bath, shower, or bed bath at least weekly and pro re nata (PRN- as needed). -Nursing would update bathing schedule as needed. 1. […]

• No harm, potential for more than minimal, patternF678Sep 28, 2023

  Based on interview and record review, the facility failed to have a process in place to ensure Cardiopulmonary Resuscitation (CPR- an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who was in cardiac arrest) certified staff were available on all shifts. The facility census was 47 residents. […]