Lutheran Retirement Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Aug 19, 2024

  Based on clinical record review, staff interview, policy and procedure review, the facility failed to provide an environment free from sexual abuse for residents who didn't have the mental capacity to consent to sexual contact for 1 of 30 residents Resident #1). In addition, the facility failed to prevent a cognitive resident from having sexually aggressive behavior, such as inappropriate touching, grabbing, and fondling for 1 of 30 residents (Resident #2). On three separate occasions reflected Resident #2 fondled and touched Resident #1 underneath her clothes with the staff unaware of the situation. The facility failed to separate the 2 residents after the first and second incidents (4/15/24, and 5/1/24 in the common area). […]

• Immediate jeopardy, isolatedF609Aug 19, 2024

  Based on clinical record review, staff interview, and facility policy/procedure the facility failed to report an allegation of abuse to the Department of Inspections, Appeals, and Licensing (DIAL) following the observation of a male resident putting a female resident's hand inside his bib overalls or the continued instances of him putting his hand down the female resident's shirt for 2 of 5 residents reviewed (Residents #1 and #2). The failure to report the incident resulted in an immediate jeopardy situation. See citation F600 for additional information. […]

• Immediate jeopardy, isolatedF610Aug 19, 2024

  Based on clinical record review, policy review, staff interview, the facility staff failed to thoroughly investigate all allegations of abuse, and separate a possible abuser from other residents. The facility lacked documentation of thorough investigations. In addition, the facility failed to conduct resident and staff interviews to determine the extent of the allegations, and if other residents were involved. The facility failed to separate the two residents until the incident occurred a third time and the family had to request something be done. After the facility added an intervention to monitor first Resident #2, then Resident #1's location, the facility failed to document as indicated. […]

• Actual harm, isolatedF600Aug 6, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure residents were protected from physical abuse and mental anguish, and failed to provide adequate supervision and effective behavioral interventions to prevent resident-to-resident altercations and intrusions for 4 of 4 residents reviewed for behaviors and safety (Resident #1, Resident #2, Resident #3, and Resident #4). The facility reported a census of 34 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, indicating severely cognitively impaired. Resident #1 demonstrated an ability to understand and be understood by others with no vision problems. […]

• Actual harm, isolatedF689Nov 20, 2023

  Based on clinical record review and staff interviews the facility failed to provide adequate supervision and follow physicians order's which resulted in a fall with injury for 1 of 1 residents reviewed (Resident #1). The facility reported a census of 33 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 4/27/23 documented a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate impaired cognition. The MDS revealed diagnoses of anemia, dementia, hypertension, generalized muscle weakness and chronic kidney disease stage 3. A Care Plan focus area revised 4/26/23 documented Resident #1 to be assist of one with front wheeled walker as of 3/30/23 and to have a motion sensor when in bed or in recliner as of 3/27/23. […]