Lutheran Rehabilitation and Skilled Care Center

In the surveyor’s words

From the most serious findings on record at Lutheran Rehabilitation and Skilled Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Feb 14, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a splint to secure a fracture he/she sustained to his/her right arm, the Facility failed to ensure he/she was provided care and treatment that met professional standards of practice, when after a follow-up appointment, Resident #1's orthopedist recommended that Nursing remove the splint daily for hygiene. However, the recommendation were not implemented by Nursing and he/she developed a pressure injury and osteomyelitis in his/her right elbow, and required surgical intervention. […]

• No harm, potential for more than minimal, patternF812Jul 19, 2021

  Based on policy review, observation and interview, the facility failed to ensure that kitchen sanitation and food/beverage storage was in accordance with Professional Standards for Food Service Safety to minimize the risk for food borne illness. Findings include: Review the facility's Food Safety Requirement Policy, dated 11/01/18, indicated the following: -The facility should follow proper sanitation and food handling practices to prevent the outbreak of food borne illness. -Food and beverages brought in for residents: Food requiring refrigeration will be received by the facility designees for proper and immediate storage, including labeling and dating. […]

• No harm, potential for more than minimal, patternF880Jan 14, 2021

  Based on observations, interviews and facility policy review, the facility failed to implement infection control procedures to reduce the possible transmission of communicable diseases including COVID-19 by failing to (1.) properly wear Personal Protective Equipment (PPE) on 2 of 2 resident units (2.) perform hand hygiene when indicated and (3.) during a COVID-19 outbreak, avoid placing residents in the same room with residents who have conditions that may increase the risk of an adverse outcome from infection or that may facilitate transmission. […]

• No harm, potential for more than minimal, isolatedF656Feb 14, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was admitted with a supracondylar fracture (near the elbow) of the right humerus (long bone in the upper arm) that was immobilized with a splint and who was assessed by nursing to be at increased risk for the development of pressure injuries, the Facility failed to ensure that Resident #1's comprehensive individual Plans of Care related to Activities of Daily Living and Potential for Pressure Ulcers, were updated after an Orthopedic Consultation and identified and described recommendations for interventions staff were to implement and follow in an effort to maintain his/her skin integrity. […]

• No harm, potential for more than minimal, isolatedF842Feb 14, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when recommendations for new treatment orders from his/her Orthopedic Consultation, despite being reviewed and approved by the Nurse Practitioner, were not transcribed onto Resident #1's Treatment Administration Record (TAR) and his/her Care Plans were not updated with new interventions. Findings include: Resident #1 was admitted to the Facility in November 2022, diagnoses included Fracture of shaft (a break of the thigh bone between the hip and the knee) of left femur, Dementia, severe, with other behavioral disturbances, Hypertension, Gastro-esophageal reflux disease, Osteoarthritis, Iron deficiency anemia,… […]