Every finding on record at Lutheran Sunset Home

Based on observation, review of the facility's policy, review of facility housekeeping checklist, and resident and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 5 of 19 sampled residents (Resident #10, #13, #42, #47, and #82) Failure to maintain clean equipment and ensure a safe, clean, and sanitary environment may result in injuries, diminish the homelike living area for residents, and does not promote overall quality of life. Findings include: Review of the facility policy, Personal Fans, occurred on 02/26/26. This policy, dated February 2025, stated, . Personal fans must be cleaned and disinfected on a routine basis . Cleaning of personal fans shall be done no less than monthly by environmental services staff. Observations on February 23-24, 2026, showed the following: -Resident #10's room: Dust/debris on a small oscillating fan. The resident stated, The rooms get cleaned every week; however, the fans don't get cleaned often. -Resident #13's room: Dust/debris on a small oscillating fan. The resident stated staff clean fans when they have time. During an interview on 02/25/26 at 8:15 a.m., an environmental staff member (#6) stated staff should clean personal fans monthly. -Observation of Resident #42's room on 02/23/26 at 1:54 p.m. identified an area approximately 5-inch by 3-inch in size missing paint. -Observation of Resident #47's room on 02/23/26 at 2:03 p.m. identified missing paint and sharp/rough pieces of wood on the cabinet under the sink, and walls missing paint. -Observation of Resident #82's bathroom on 02/23/26 at 2:07 p.m. showed moisture damage to the wall and warped molding. During an interview on the afternoon of 2/26/26, an environmental staff member (#6) confirmed Resident #42, #47, and #82's rooms needed repair.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure dishware and eating utensils are properly cleaned and sanitized in 1 of 1 kitchenette (Special Care Unit) utilizing a mechanical dish-washing machine. Failure to ensure the mechanical dishwashing machine reaches the proper temperatures for the wash and final rinse cycles may result in unclean and unsanitized dishware and eating utensils. Findings include:The 2022 FDA (Food and Drug Administration) Food Code, Public Health Reasons, pages 172 - 153, stated . 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. The wash solution temperature in mechanical warewashing equipment is critical to proper operation. The chemicals used may not adequately perform their function if the temperature is too low. Therefore, the manufacturer's instructions must be followed. The temperatures vary according to the specific equipment being used. 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. The temperature of hot water delivered from a warewasher sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multiuse utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning. The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization. The . temperature limits of (180 F) .are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature.Review of the facility policy, [NAME] SR24 Dish Sanitizer (SCU) [Special Care Unit] occurred on 02/26/26. This policy, dated January 2025, stated, Purpose: Sanitize dishes that have been handwashed in the Special Care Unit. Procedure: 1. Wash all dishes in the sink with hot soapy water to remove all food debris. Rinse and put on a rack in the dish sanitizer in a single layer. 4. Sanitation accomplished by means of a built-in . electric booster .designed to raise the water to 180 [degrees] F [Fahrenheit] . 5. Minimum Water Temperature - Wash Cycle 150 [degrees] F Rinse Cycle 180 [degrees] F .Observation of the Special Care Unit kitchenette occurred on 02/26/06 at 11:55 a.m. with a supervisory dietary staff member (#4). Observation showed a mechanical dish-washing machine, which is used three times a day for washing dishware and utensils. The dietary staff member identified the dishwasher uses heat to sanitize the dishware and utensils. When asked to see the temperature log of wash and rinse temperatures, an unidentified staff member on the unit stated they do not check the temperature gauges on the dish machine and they have never kept a log. The surveyor placed an irreversible temperature measuring device in the dish machine and the dietary staff member (#4) started the dish machine. The temperature of the wash cycle and the rinse cycle did not reach the minimum temperatures per policy. The dietary staff member started the dishwasher for a second cycle and the wash gauge reached 155 degrees F, the rinse temperature reached 195 degrees, and the irreversible temperature measuring device reached 165 F. The dietary staff member (#4) confirmed staff should monitor the dish machine to ensure the proper temperature is reached to wash and sanitize the dishware and utensils.

Based on observation, record review, and review of facility policy, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity for 2 of 19 sampled residents (Resident #2 and #8). Failure to provide privacy to residents while in their room has the potential to affect the residents' psychosocial wellbeing and does not enhance the residents' quality of life. Findings include: Review of the facility policy titled Resident Rights occurred on 02/26/26. This policy, dated 11/17/16, stated, . 1. Resident rights. The resident has the right to a dignified existence . -Review of Resident #2's medical record occurred on all days of survey. The care plan stated, .Total dependence with toileting hygiene, product change and clothing adjustment . Observation on 02/24/26 at 8:52 a.m. and 9:28 a.m. showed Resident #2's room door ajar and the resident lying in bed uncovered with pants pulled down under the buttocks and the brief exposed. -Review of Resident #8's medical record occurred on all days of survey. The care plan stated, Problem: Generalized pruritis [itchy skin] . sits with no clothes on in .room . fabric causes . itch. doesn't like . door to . room closed tight so a curtain was placed in . room to provide privacy when . in . room naked. Observations of Resident #8 on 02/26/26 at 8:26 a.m. and at 10:25 a.m. showed Resident #8 asleep in a recliner, naked from the waist down, and the door to the room open. Staff failed to use the privacy curtain which left the resident exposed to visitors, staff, and other residents.

Based on record review, review of the facility reported incident (FRI) reports, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from resident-to-resident altercations for 2 of 2 sampled residents (Resident #2 and #37) subjected to physical and sexual abuse from other residents. Failure to protect residents from physical or sexual abuse placed Residents #2 and #37 and all other residents at risk for mental and emotional distress, and injury.Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 02/25/26. This policy, revised 02/13/24, stated, . Residents must not be subject to abuse by anyone, including . other residents. 'Abuse' means the willful infliction of injury . 'Sexual Abuse' in non-consensual sexual contact of any type with a resident . 'Physical Abuse' includes . hitting .Incident between Resident #37 and Resident #87The initial FRI report, dated 08/30/25, stated, . 08/30/25 at approximately 12:55 p.m. [Resident #87] was witnessed by a CNA [certified nurse aide] touching and kissing [Resident #37] in [Resident #37's] room . CNA immediately notified RN [registered nurse] and LPN [licensed practical nurse] and immediately intervened, separating [Residents #37 and #87]. The final FRI report indicated Resident #37 denied providing consent, a provider deemed Resident #37 unable to consent to sexual activity/relationship due to her cognition, and Resident #87 felt Resident #37 comes seeking attention from him and Resident #37 kissed him first.Review of Resident #37's medical record occurred on all days of survey. Diagnoses included Alzheimer's Disease, dementia with behaviors, mild intellectual disabilities, and obsessional thoughts and acts. A quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition. The care plan stated. becomes fixated [sic] things. will often times repeat the same phrase over and over again . seeks out male attention. sometimes make [sic] unsafe decisions .Review of Resident #37's progress notes identified the following:*08/30/25 at 3:16 p.m., stated, . Notified by staff that resident [Resident #37] was found in her room on her bed, with [Resident #87]. Staff reported he witnessed [Resident #87] kissing resident and feeling her breasts under her shirt. Writer and second nurse witness [sic] [Resident #87] sitting on bed next to resident. He was leaning over her with his torso and kissing her. He was also seen touching her breasts with hand under shirt. Resident did not show any signs of distress such as screaming, hitting, or moving from [Resident #87]. Staff separated residents from each other. Skin assessment completed with no apparent injuries noted.*09/02/25 at 10:45 a.m., stated, . LATE ENTRY . A comprehensive interview was conducted with resident . Resident [Resident #37] did concede that a male resident had entered her room and touched her inappropriately and stated, 'I did not like it.' .-Review of Resident #87's medical record occurred on all days of survey. Diagnoses included dementia with behaviors. An annual MDS, dated [DATE], identified intact cognition. The care plan stated, . has a behavior problem r/t [related to] making inappropriate touching, kissing, and comments towards females at times. Resident did have an episode of touching a female resident on 8/30/2025.A progress note, dated 08/30/25 at 3:44 p.m., stated, . Resident was seen in [Resident #37's] room. He was sitting next to her on her bed while she was lying down. Resident had his hand under her shirt and was kissing her face. Resident was escorted out of [Resident #37's] room back to his room by nursing staff. Incident between Resident #2 and Resident #40During an interview on 02/23/26 at 1:33 p.m., Resident #40 stated there is too much noise outside his room and indicated he had hit other residents.-Review of Resident #40's medical record occurred on all days of survey and identified diagnoses of psychosis, delusions, intermittent explosive disorder, traumatic brain injury, and mild intellectual disabilities. A quarterly MDS, dated [DATE], identified moderately impaired cognition. The care plan stated, . He is not orientated to time and has difficulty with recall. 'explodes' . if there is a lot of noise. He has hit other residents in the fact [sic] and pushed them with his 4WW [wheeled walker]. When it gets too loud outside his room, he may start yelling to 'Shut up!' .A progress note, dated 08/24/25 at 7:00 p.m., stated, . Dietary aide reported to writer that this resident [Resident #40] had struck another resident [Resident #2] on the cheek. no injury noted but the resident was confused. Writer spoke with this resident [Resident #40], and he stated that he did it because she [Resident #2] is always making noise out by the nurse station and it bothers him in his room. Writer told resident that it is never okay to be physically aggressive with another resident. He then stated that she deserved it because she never gets in trouble for making noise.-Review of Resident #2's medical record occurred on all days of survey and identified diagnoses of Alzheimer's Disease, dementia with psychotic disturbance, hallucinations, and anxiety. A quarterly MDS, dated [DATE], identified severely impaired cognition. A progress note, dated 08/24/25 at 7:11 p.m., stated, . Dietary aide reported that this resident [Resident #2] had been struck on the cheek by another resident [Resident #40] when he was going to the dining room. She stated that the male resident stopped and said something to this resident and when she made a noise, he had struck her, hard, on the cheek. Writer assessed resident and found no injury present. Writer asked resident if she was okay and she said yes but she doesn't think he likes her very much.During an interview on 02/25/25 at 2:55 p.m., an administrative staff member (#11) confirmed the facility investigated incidents that occurred on 08/24/25 and 08/30/25. The facility failed to protect Resident #2 from physical abuse and Resident #37 from sexual abuse.

Based on record review, review of facility policy, and staff interview, the facility failed to report potential abuse for 1 of 2 sampled residents (Resident #2) and 1 supplemental resident (Resident #40) reviewed for resident-to-resident altercations. Failure to report potential abuse to the State Survey Agency (SSA) placed Resident #2 and all other residents at risk for possible abuse and/or physical injury.Findings include:Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 02/25/26. This policy, dated 02/13/24, stated, . Ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents [sic] that cause the allegation do not involve abuse and do not result in serious bodily injury to the . State Survey Agency . Report the results of all investigation to the . State Survey Agency, within 5 working days of the incident .-Review of Resident #2's medical record occurred on all days of survey and identified diagnoses of Alzheimer's Disease, dementia with psychotic disturbance, hallucinations, and anxiety. A quarterly MDS, dated [DATE], identified severely impaired cognition. A progress note, dated 08/24/25 at 7:11 p.m., stated, . Dietary aide reported that this resident [Resident #2] had been struck on the cheek by another resident [Resident #40] when he was going to the dining room. She stated that the male resident stopped and said something to this resident and when she made a noise, he had struck her, hard, on the cheek. Writer assessed resident and found no injury present. Writer asked resident if she was okay and she said yes but she doesn't think he likes her very much.-Review of Resident #40's medical record occurred on all days of survey and identified diagnoses of psychosis, delusions, intermittent explosive disorder, traumatic brain injury, and mild intellectual disabilities. A quarterly MDS, dated [DATE], identified moderately impaired cognition. The care plan stated, . He is not orientated to time and has difficulty with recall. 'explodes' . if there is a lot of noise. He has hit other residents in the fact [sic] and pushed them with his 4WW [wheeled walker]. When it gets too loud outside his room, he may start yelling to 'Shut up!' .During an interview on 02/25/25 at 2:55 p.m., an administrative staff member (#11) confirmed the facility failed to report the above incident to the SSA. See F600

Based on record review and staff interview, the facility failed to ensure resident records contained the hospice election form for 1 of 1 closed record (Resident #85) who received hospice services. Failure to obtain the election form may have limited staff's ability to ensure coordination of care between the facility and the hospice. Findings include: Review of Resident #85's medical record occurred on 02/26/26 and identified the following:* A nurse's note dated 01/02/26 at 2:46 p.m., stated, . Phone call made to [physician's name] office regarding decline in [name] condition change. Hospice referral given by [provider's name] .* A nurse's note dated 01/07/26 at 1:32 p.m., stated, Hospice nurse visit completed to assess patient status. The medical record lacked the hospice election form. During an interview on 02/26/26 at 10:03 a.m., a facility staff member (#2) confirmed the medical record for Resident #85 lacked the hospice election form.

Based on observations, review of the Resident Council minutes, and resident interview, the facility failed to follow standards of practice for infection control for 1 of 1 sampled resident (Resident #82) who received nebulizer treatments. Failure to ensure nebulizer masks and tubing are on a clean surface may result in contamination of the items and lead to respiratory infections. Findings include: Review of Resident Council Meeting minutes occurred on 02/25/26. The meeting minutes, dated 10/17/25, identified two residents had concerns regarding nebulizer tubing left lying on the floor. -Observations on 02/23/26 at 2:07 p.m. and 3:25 p.m., on 02/24/26 at 8:37 a.m., and on 02/26/26 at 12:56 p.m. showed a nebulizer mask and tubing on the floor next to Resident's #82's recliner. During an interview on 02/26/26 at 12:56 p.m., Resident #82 stated the nebulizer machine, mask, and tubing are always on the floor.

Based on observation, record review, policy review, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 18 sampled residents (Resident #2, #33, #75, and #236) and 2 supplemental residents (#9 and #43) observed. Failure to practice infection control standards related to enhanced barrier precautions (EBP), transmission-based precautions (TBP), and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Droplet Precautions occurred on 12/19/24. This policy, dated July 2022, stated, Residents suspected of or confirmed to have COVID-19 will be placed on Enhanced Droplet Precautions . Doffing [removing] PPE [personal protective equipment] . Remove gloves immediately outside the room. Take care to not touch the contaminated surface of the glove. Perform hand hygiene. Remove gown . Remove goggles. Remove N95 mask. Perform hand hygiene . Review of the facility policy titled Enhanced Barrier Precautions occurred on 12/19/24. This policy, dated April 2024, stated, . PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include: . dressing . transferring . changing briefs . Review of the facility policy titled Standard Precautions occurred on 12/19/24. This policy, dated December 1996, stated, Standard Precautions incorporates previous CDC [Centers for Disease Control] recommendations for universal precautions, patient care equipment . The major emphasis is on the use of gloves and other protective equipment, devices, and controls to prevent or reduce hand, skin, and mucous membrane contact with blood and other potentially infectious materials. Standard Precautions should be used for all residents at all times . The precautions apply to . feces .Gloves should be worn for . handling items or surfaces soiled with these substances . Hands should be washed immediately after gloves are removed. Gowns should be worn during procedures . when soiling with these substances is likely . -Review of Resident #2, #43, and #236's medical records occurred on all days of survey and identified diagnoses of Covid-19 infection. Observation on 12/16/24 at 2:30 p.m., showed a certified nurse aide (CNA) (#9) exited Resident #43 and #236's shared room wearing PPE and carrying two used drinking glasses. The CNA (#9) set the two glasses on a table outside of the residents' room, removed her PPE and placed the glasses in the container with the dirty dishes. The CNA applied PPE and returned to the resident's room. The CNA failed to perform hand hygiene after removing PPE and before re-entering the resident's room. Observation on 12/18/24 at 10:20 a.m., showed a CNA (#10) exited Resident #2's room wearing PPE, and carried a meal tray down the hall, past the nurse's station and another resident, and placed the tray on a cart designated for dirty dishware. The CNA returned to the bin located outside the resident's room, removed her PPE and completed hand hygiene. During an interview on 12/19/24 at 10:55 a.m., an administrative staff member (#2) confirmed she expected staff to remove PPE and perform hand hygiene after leaving a Covid-19 positive room and before completing other tasks. - Review of Resident #75's medical records occurred on all days of survey. The care plan stated, Potential for UTI [urinary tract infection] related to indwelling foley catheter. Enhanced Barrier Precautions in place. Observation on 12/18/24 at 8:44 a.m., showed a CNA (#11) providing high-contact resident cares including changing the resident's brief, dressing, and transferring Resident #75. The CNA failed to wear a gown during the high-contact resident care. - Review of Resident #9's medical record occurred on 12/17/24 and identified EBP. Observation on 12/17/24 at 2:35 p.m. showed two CNAs (#10 and #11) performed hand hygiene, applied gowns and gloves, and changed Resident #9's brief soiled with bowel movement (BM). The CNA (#10) removed the resident's brief, cleansed the perineal area, removed her gloves and without performing hand hygiene, applied clean gloves. The CNA (#11) cleansed the resident's hands of BM, removed her gloves and without performing hand hygiene, applied clean gloves. Both CNAs applied a clean brief and clean linens to the resident's bed. The CNAs (#10 and #11) failed to perform hand hygiene after removing soiled gloves and before performing other tasks. - Observation on 12/19/24 at 5:00 p.m. showed a nurse (#15) entered Resident #33's room and without performing hand hygiene, donned gloves, checked the resident's blood sugar, removed the gloves, and again without performing hand hygiene, exited the resident's room. At the nurses' station, the nurse (#15) placed the glucometer on top of the medication cart, obtained an alcohol wipe and gloves from the cart, and returned to Resident #33's room. The nurse donned gloves without performing hand hygiene, administered insulin, exited the room and threw the gloves in the trash can. The nurse failed to perform hand hygiene throughout the observation. During an interview on 12/19/24 at 10:55 a.m., an administrative staff member (#2) confirmed staff should perform hand hygiene between glove changes. 46963

45873 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 18 sampled residents (Resident #24 and #35) and 1 supplemental resident (Resident #40). Failure to accurately code the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION N: MEDICATIONS The Long-Term Care Facility RAI 3.0 User's Manual, revised October 2024, page N-7 stated, . N0415G1. Diuretic: Check if a diuretic medication was taken by the resident at any time during the 7-day look-back period . - Review of Resident #24's medical record occurred on all days of survey. Medications included and identified Furosemide (a diuretic) daily. Review of the quarterly MDS, dated [DATE], showed the facility failed to code diuretic use. SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS The Long-Term Care Facility RAI User's Manual, revised October 2024, pages O-3, O-4, and O-7, stated, . Coding Instructions for Column b. While a resident. Check all treatments, procedures, and programs that the resident received or performed . within the last 14 days. O0110C1, Oxygen therapy. Code continuous or intermittent oxygen administered via mask, cannula, etc. O0110K1, Hospice care. Code residents identified as being in a hospice program . - Review of Resident #24's medical record occurred on all days of survey. A physician's order, dated 03/13/24, stated, admitted to Hospice . Review of the significant change MDS, dated [DATE], showed the facility failed to code hospice services. - Review of Resident #40's medical record occurred on all days of survey. Physician's orders identified the resident admitted to hospice services on 10/21/24. Review of the significant change MDS, dated [DATE], showed the facility failed to code hospice services. - Review of Resident #35's medical record occurred on all days of survey. A physician's order, dated 05/31/24, stated, . Oxygen 2L [liters per minute] via NC [nasal cannula] PRN [as needed] to keep sats [oxygen saturation level] greater than 90% . A quarterly MDS, dated [DATE], showed the facility failed to code oxygen use. The resident's medication administration record (MAR), dated 10/30/24 to 11/13/24, identified oxygen use. During an interview on 12/18/24 at 4:25 p.m., an administrative nurse (#3) confirmed staff miscoded the MDS's.

Based on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 18 sampled residents (Resident #1 and #35). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 12/19/24. This policy, dated 11/17/16, stated, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment . - Review of Resident #1's medical record occurred on all days of survey. The current care plan stated, . Potential for bleeding related to anticoagulant [medicine that increases the time for blood to clot] use. Apixaban [blood thinner] as ordered by MD [medical doctor] . Review of the October 2024 Electronic Medication Administration Record (eMAR) showed the provider discontinued Apixaban on 10/30/24. During an interview on 12/18/24 at 10:26 a.m., an administrative nurse (#2) confirmed staff failed to revise Resident #1's care plan following the discontinuation of the anticoagulant. - Review of Resident #35's medical record occurred on all days of survey. Diagnoses included chronic obstructive pulmonary disorder (COPD) (restricted airflow in the lungs), shortness of breath, and chronic heart failure (CHF). A physician's order, dated 05/31/24, stated, Oxygen 2L [liters per minute] via NC [nasal cannula] PRN [as needed] to keep sats [oxygen saturation level] greater than 90% . A quarterly MDS, dated [DATE], identified the resident as cognitively intact and independent with activities of daily living. During an interview on 12/17/24 at 9:23 a.m., Resident #35 stated he/she uses oxygen when I feel winded. The resident confirmed he/she independently uses the oxygen concentrator and portable oxygen tank, and stated, I sometimes turn it [the meter flow] up until it pops to clear out the tube and then turn it back down. Resident #35's care plan failed to include Resident #35's independent use of oxygen and education on the risks of this practice. During an interview on 12/17/24 at 4:31 p.m., an administrative nurse (#2) confirmed Resident #35 removes and applies their own oxygen, and stated, They [facility staff] have educated [resident] on oxygen. 46963

Based on observation, record review, review of manufacturer's instructions for use, and staff interview the facility failed to ensure staff followed standards of practice for 2 of 2 residents (Resident #33, and #235) who required rapid acting insulin. Failure to administer rapid acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction. Findings include: Prescribing information for Humalog insulin (a raid acting insulin), found at https://www.humalog.com, stated, Administer HUMALOG . within 15 minutes before a meal or immediately after a meal. Prescribing information for Novolog insulin, found at https://www.novolog.com, stated, Novolog is a rapid-acting insulin . Novolog starts acting fast. Eat a meal within 5-10 minutes after taking it. - Review of Resident #235's medical record occurred on 12/18/24. Current physician's order included Humalog insulin 50 units three times a day. During an interview on 12/18/24 at 5:16 p.m., a nurse (#15) stated she checked Resident #235's blood sugar at 4:45 p.m., obtained a blood glucose reading of 125 milligrams/deciliter (mg/dl), and administered 50 units of Humalog. Observation on 12/18/24 of Resident #235 showed the following: * 5:17 p.m., at a table in the dining room. * 5:37 p.m., received two glasses of juice at the table. (52 minutes later) * 5:48 p.m., received the evening meal (one hour and 3 minutes after receiving a rapid acting insulin). - Review of Resident #33's medical record occurred on all days of survey. Current physician's order included, Aspart (Novolog Insulin) 30 units in the evening and hold if resident does not eat. Observations on 12/18/24 showed the following: * 5:00 p.m., a nurse (#15) administered 30 units of Novolog to Resident #33. * 5:28 p.m., Resident #33 received her evening meal. (28 minutes after receiving a rapid acting insulin). During an interview on 12/19/24 at 10:26 a.m., an administrative nurse (#2) stated she expected staff to serve a meal within 15 minutes of administering a rapid acting insulin.

Based on observation, record review, and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 3 sampled residents (Resident #75) observed during transfers. Failure to utilize a gait belt during transfers placed the resident at risk for falls and/or injury. Findings include: Review of the policy titled Gait belt For Transfers occurred on 12/19/24. This policy, dated September 2002, stated, . Gait belts are provided to assist staff to safely transfer or ambulate residents. Observation on 12/18/24 at 8:44 a.m., showed a certified nurse aide (CNA) (#11) provided personal cares to Resident #75. After personal cares were provided, the CNA (#11) placed both hands on the resident's buttocks to assist the resident to sit in the wheelchair. The CNA failed to utilize a gait belt during the transfers. Review of Resident #75's medical record occurred on all days of survey. The care plan, dated 11/16/24, stated, . Assist of 1 with gait belt for transfers. The facility failed to ensure staff followed Resident #75's plan of care and use a gait belt during transfers.

Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure food is served and stored in accordance with professional standards for food service sanitation in 1 of 1 kitchen (main kitchen). Failure to ensure a reach-in freezer remains free of frozen water/condensation and ensure proper glove usage when serving ready-to-eat foods has the potential to result in foodborne illness and may result in adverse consequences for residents, visitors, and staff. Findings include: Review of the facility policy titled USE OF PLASTIC GLOVES occurred on 12/19/24. This policy, dated 2005, stated, . If used, single use gloves shall be used for only one task . used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. ANYTIME A CONTAMINATED SURFACE IS TOUCHED, THE GLOVES MUST BE CHANGED. The 2022 Food and Drug Administration (FDA) Food Code, page 81, stated, . 3-305.11 Food Storage. FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . Annex 3 Page 384, stated, . 3-305.12 Food Storage, Prohibited Areas. Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate . can be sources of microbial contamination for stored food. Observation on 12/16/24 at 1:37 p.m. showed a large amount of ice build-up on the back wall of a reach in freezer extending from the top to the bottom floor of the freezer, ice accumulation on top of a box containing ice cream bars and several closed boxes placed on top of the ice build-up on the bottom of the freezer. When asked about the ice accumulation, a dietary manager (#12) stated, I am not sure why this happens. Maintenance takes care of this for us. I guess it's that time again. Observation of the tray line in the main kitchen on 12/17/24 at 12:00 p.m. showed a dietary staff member (#13) wore gloves while using utensils to dish food onto residents' plates. The staff member removed a food item from a warming oven, pushed a plate warmer cart out of his/her way, and without changing gloves, reached into a bag and placed bread onto a resident plate. The staff member (#13) failed to change gloves after touching non-food areas and before handling ready-to-eat food.

Based on record review, review of facility policy, and staff interview, the facility failed to ensure the coverage of 1 of 1 surety bond provided the required coverage of all personal funds for residents who deposited money with the facility. Failure to ensure the security bond covered all funds entrusted to the facility may result in the residents suffering financial losses secondary to the facility failing to hold, safeguard, manage, and/or account for their funds. Findings included: Review of the facility policy titled Resident Trust Funds occurred on 12/19/24. This policy, dated November 2000, stated, . The facility maintains a security bond to protect the resident's funds. During an interview on 12/18/24 at 3:33 p.m., a business office staff member (#14) reported the residents' trust fund account currently contained $10,138.13. An administrative staff member (#1) showed the surveyor an insurance document, with an effective date of 03/11/23, which showed a bond limit of $10,000.00. The facility failed to implement a system ensuring they maintained a surety bond that covered all personal funds entrusted to the facility.

1. Based on record review, resident and staff interviews, and review of a facility reported incident, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #1) reviewed for an accident with subsequent injury. Failure to follow facility policy for proper use of a stand-lift resulted in injury. Findings include: Review of Resident #1's medical record identified diagnoses of osteoarthritis and abnormalities of gait (walking). The care plan identified, . Self-care deficit with mobility related to decreased mobility, . and other risk factors. Assist of 1 with stand aid lift for all transfers. Record review occurred on 05/21/24. The nurse's notes identified the following: 4/30/24 4:08 p.m. CNA [certified nurse aide] called nurse into resident's room @ [at] 6:30 AM. Showed nurse resident's bruise to right rib area and right breast area. Nurse assessed and measured bruise. Resident was being transferred from chair to bed with stand aid lift when bruise occurred. Resident denied pain @ this time. Assessed and measured resident [bruised area]. 18 cm (L) [centimeters in length] X 26 cm (W) [centimeters in width] dark purple bruise to right rib area and right breast area. Reported to . Nurse Manager . COTA [certified occupational therapy assistant] . checked lift for proper functioning. Machine cleared. Pain assessment completed. Resident denied pain throughout shift. During an interview with Resident #1 on 05/21/24 at 11:00 a.m., the resident stated she has been a resident at the facility for eight years. When asked about the incident that caused the bruises she described, I was all bruised along my chest and down my leg. She [CNA] had that lift backwards. It was so painful, and I told her it was wrong, and I was hurting but she ignored me. The resident explained she had never had that happen to her before or since the episode on 4/28/24. The resident acknowledged the bruises did not show up until a couple of days later and the two nurses that came to check on me were so upset and said, 'what in the world happened here?' So, I told them . During an interview with a staff member (#8) on 05/21/24 at 1:00 p.m., the staff member stated she observed bruises on the resident's chest area while assisting the resident on the morning of 04/30/24. The staff member said she was stunned to see the bruising and wondered what happened. She immediately reported it to the charge nurse. The staff member said the resident often talks about being scared now when being lifted and she had not expressed that fear before. Review of the Facility Reported Incident investigation identified, . It was noted on 4-30-24 during AM [morning] cares that [resident] has a very large bruise to her right breast mid nipple line and down and to the side area that is black /blue in color. Bruised area measures 18 x 26 cm. When [resident] was asked about the bruise, [resident] stated that two evenings ago (04/28/24) she kept telling the new CNA that the lift was hurting her, but the CNA wouldn't listen to her and kept talking over her as she proceeded with the transfer despite [resident's] continued complaints of pain. During an interview on 05/21/24 at 2:45 p.m., two administrative staff members (#1 and #2) confirmed they expected staff to follow the proper procedure for stand lift transfers. The facility failed to ensure staff followed appropriate procedure for a transfer with a sit to stand lift. 2. Based on record review, staff interviews, review of facility policy, and review of a facility reported incident, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #3) reviewed for an accident with subsequent injury. Failure to follow facility policy for proper use of a maxi-lift (mechanical full body lift) resulted in injury. Findings include: Review of the facility policy titled Mechanical Lift - Total Lift occurred on 05/21/24. This policy, revised December 2022, stated, Purpose: A mechanical lift is used appropriately to facilitate transfer of residents. *The mechanical lift is used by nursing staff. *Two persons are needed to use mechanical lift unless indicated by resident's care plan. Procedure: 3. Place lift sling under the resident; position lift over resident. 4. Attach sling clips to lift, making sure they are attached snugly. Review of Resident #3's medical record identified diagnoses of dementia and muscle weakness. The current care plan identified, . Self-care deficit related to osteoarthritis, . and other risk factors. Assist X 2 [two staff people] with maxi lift for all transfers. Record review occurred on 05/21/24. The nurse's notes identified the following: *02/23/24 at 10:32 a.m. CNA's states [sic] while lifting resident in maxi lift didn't realize straps were not properly attached causing resident to fall back and hit her head on the floor causing laceration [cut] 1 cm [centimeter] x 0.1 cm. Assist x 2 to lift resident up off floor back into her wheelchair. Writer and treatment nurse assessed resident's laceration, cleansed with NS [normal saline] applied steri strips [a type of band aid used to hold wound edges together]. Writer called [providers office] spoke to Nurse [name] states to monitor, neuro [neurological] checks every two hours and call if any other concerns. Education given to staff in prevention of future falls, to assure maxi lift sling is properly in place when attempting to lift resident. *2/27/24 11:00 a.m. f/u [follow up] to fall on 2/23/24: 2 CNAs were assisting [resident] to use the commode per maxi lift. Lift sling was properly connected between [resident's] legs, but the top hooks were not connected; neither CNA confirmed correct placement prior to lifting [resident] into the air and as she was being lift [sic], [resident's] body weight shifted her backward on her w/c [wheelchair], causing her to fall back and hit her head on the floor. [Resident] sustained a 1 cm x 0.1 cm laceration to the back of her scalp . During an interview on 05/21/24 at 1:15 p.m., a staff member (#4) stated she thought the other CNA in the room said, I hooked the back clips, but instead she said, you need to hook the back clips. She said they miscommunicated. Review of the Facility Reported Incident investigation identified, . [Resident] was being transferred from her wheelchair with the use of the maxi lift. CNA used the remote on the maxi lift to lift [resident] up in the maxi lift while [other] CNA was elsewhere in the room. Bottom lift sling clips were clipped, but upper lift sling clips were not clipped causing [resident's] wheelchair to tip backward and [resident] to fall backward and hit head on the floor. [resident] sustained a 0.1 x 1 cm laceration to the back of head. During an interview on 5/21/24 at 2:45 PM, two administrative staff members (#1 and #2) confirmed they expected staff to follow the proper procedure for mechanical full body lift transfers. The facility failed to ensure staff followed mechanical lift procedures which resulted in injury. Based on the following information, non-compliance at F689 is considered past non-compliance. The facility implemented the corrective action for the resident affected by the deficient practice by: *Completing an investigation with interviews of staff who assisted with the transfer on 02/23/24. *Determining staff failed to follow the Maxi-lift policy and resulted in a resident's fall with injury. *Providing 1 on 1 education immediately after the incident with involved staff regarding proper use of Maxi-lift and sling with return demonstration to the rehabilitation manager. The facility addressed measures put in place and implemented systemic changes to ensure the deficient practice does not recur by: *Providing education to all nursing staff on proper mechanical lift transfers on 04/09/24. The survey team determined a deficient practice existed on 02/23/24. The facility implemented corrective action on 02/23/24 and completed nursing education on 04/09/24.

Based on record review, review of facility policy, and staff interview, the facility failed to report alleged violations involving neglect to the State Survey Agency (SSA) for 1 of 1 sampled resident (Resident #1) who eloped from the facility. Failure to report allegations and submit investigation results placed all residents at risk for neglect. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation occurred on 01/25/24. This policy, dated 11/17/16, stated, . Neglect means failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: . Contact the State Agency and the local Ombudsman office to report the alleged abuse. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . to the Administrator of the facility and to other official [sic] (including the State Survey Agency .) in accordance with State law. Review of Resident #1's medical record occurred on 01/25/24. Nurses' notes identified the following: *01/23/24 at 2:32 a.m., . CNA [certified nurse aide] was doing rounds at 12:05 [a.m.] and resident was not in his room. While searching rooms down the hallway CNA heard banging on a window outside door number 8. He was sitting in a patio chair outside the first apt [apartment]. CNA helped him back inside. He stated he was going out for gas and got locked out. He had fallen outside and was very cold. He was brought to his room and changed into warm, dry clothes and covered with warm blankets. He sustained an abrasion to the top of his left forehead and to the outer side of his left hand and both knees were red. As he was warming up his hand and fingers continued to be very cold and all his fingertips on both hands had darkened. Call placed to ER [emergency room ] and informed ER nurse and aware that resident was coming to the ER. Ambulance here and picked up resident at 1:30 am and was transferred to [medical facility]. *01/23/24 at 6:53 a.m., . Call received from [medical facility], resident is being transferred to [burn center]. *01/23/24 at 4:02 p.m., . Did call [burn center] . and received update that [Resident #1] will be there for at least 2 more days trying to get circulation improved to fingers. The record lacked evidence the facility reported the above incident to the SSA as possible neglect. During an interview on the morning of 01/25/24, an administrative staff member (#1) confirmed the facility did not report the above incident to the SSA.

Based on observation, facility documentation, and staff interview, the facility failed to serve, prepare, and store food in a safe and sanitary manner for 1 of 1 kitchen. Failure to discard spoiled food and protect dishware from contamination has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: Observation of the main kitchen and walk-in cooler occurred on 10/30/23 at 12:40 p.m. and showed the following: * Two unopened containers of strawberries, with visible mold present. * One unopened container of cherry tomatoes, shriveled and covered with dark spots. * One open, undated bag of shredded lettuce, with visible browning present. * A tabletop fan visibly soiled with dust blowing in the direction of clean dishes. Review of the facility document titled Food Rotation Chart occurred on 11/02/23. This undated document listed various fruits and vegetables with guidance for their optimal length of storage as follows: * Tomatoes - Use by date; assess quality * Lettuce-shredded - Use by date; assess quality * Strawberries-5 days; assess quality A fan cleaning schedule provided by maintenance showed a kitchen fan initialed as cleaned on September 14, 2023. During an interview on 11/02/23 at 10:15 a.m., two dietary administrative staff (#2 and #3) stated they expected all kitchen staff to monitor the walk in cooler and discard spoiled food. A dietary administrative staff (#3) stated it is the maintenance department's responsibility to clean fans monthly and staff should not direct fans toward dishes or food preparation areas.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 1 of 20 sampled residents (Resident #132) reviewed for advance directives. Failure to ensure the medical record accurately reflected the resident's code status limited the facility's ability to communicate to direct care staff and emergency personnel the resident's choice in the event of a medical emergency. Findings include: Review of the facility policy titled Code Blue occurred on [DATE]. This policy, dated [DATE], stated, . Code Level 1 residents are identified at LSH [Lutheran Sunset Home] by a red heart on the spine end of the paper medical record. Review of Resident #132's medical record occurred on all days of survey. The ND POLST: Physician Orders for Life Sustaining Treatment, signed by Resident #132 on [DATE] and the physician on [DATE], indicated CPR (cardiopulmonary resuscitation)/Attempt Resuscitation. During an interview on [DATE] at 9:55 a.m., a licensed nurse (#4) stated full code residents have a red heart on the chart. Observation on [DATE] at 10:00 a.m. showed Resident #132's medical record lacked a red heart at the spine end of the chart. The licensed nurse (#4) confirmed the chart lacked the red heart. During an interview on [DATE] at 3:25 p.m., an administrative nurse (#1) stated she expected staff to place a red heart on the chart of a resident who elected full code/CPR as soon as the resident completed the form.

Based on observation, record review, review of a facility reported incident, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the residents' current status for 3 of 20 sampled residents (Resident #12, #30, and #50). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Reviewing and Revising the Care Plan occurred on 11/01/23. This policy, dated September 2022, stated, . The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The care plan will be updated with the new or modified interventions. - Review of Resident #12's medical record occurred on all days of survey. The facility reported incident (FRI) identified the resident displayed inappropriate physical behavior with a female resident on 10/26/23. The FRI also identified the facility updated Resident #12's care plan. Resident #12's medical record failed to identify any information related to the incident that occurred on 10/26/23. Review of Resident #12's care plan, updated 10/17/23, stated, . does make inappropriate comments towards female staff at times . The care plan failed to identify any update regarding inappropriate physical behavior with female residents or any interventions. During an interview on 11/02/23 at 9:37 a.m., an administrative staff member (#1) confirmed she expected staff to update Resident #12's care plan with information to reflect behaviors of inappropriate touching with a female resident. - Review of Resident #30's medical record occurred on all days of survey. Diagnoses included Parkinson's disease and CVA (cerebral vascular accident). A restorative nursing note, dated 06/28/23, stated, . Provided resident with a pommel anti trust (sic) wheelchair cushion to improve upright seated posture. Observation on all days of survey showed Resident #30's wheelchair with a pommel cushion in place. Resident #30's care plan lacked information related to the pommel cushion. During an interview on 11/01/23 at 1:43 p.m., an administrative nurse (#1) confirmed Resident #30's care plan lacked information related to the pommel cushion. - Review of Resident #50's medical record occurred on all days of survey. The medical record showed Resident #50 signed a Self-Administration of Medication Consent and Waiver Form on 04/20/22. This form stated, I assume the responsibility of taking my medications without direct observation. I do not wish to store medications in my room. By assuming this responsibility I agree to comply with the facilities policies and procedures for medication self -administration. I further understand that failure to comply with facility policy may result in the rescinding of my right to administer my medications. Resident #50's care plan lacked problem, goals, and interventions related to self-administration of medications. During an interview on 11/02/23 at 10:50 a.m., an administrative nurse (#1) stated she expected staff to include self-administration of medications on the care plan. 37620 45873

Based on review of Quality Assurance and Performance Improvement (QAPI) meeting minutes, facility policy, and staff interview, the facility failed to ensure participation by the medical director for 2 of 4 quarterly meetings (February 16, 2023 and August 17, 2023) reviewed. Failure to ensure the medical director participates in the facility's Quality Assurance activities deprived the committee of the physician's unique contributions for analyzing and correcting problems with identified resident care areas. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement Program occurred on 11/02/23. This undated policy, stated, . Framework: The administrator, the director of resident services, infection control & [and] prevention officer, medical director . will provide QAPI leadership by being on the QAA [quality assurance and assessment] committee. The QAA committee will meet quarterly. Review of QAPI meeting minutes occurred on 11/02/23 and identified the QAPI committee met on a quarterly basis between November 2022-August 2023. The QAPI meeting minutes identified the medical director failed to attend the meetings on February 16, 2023 and August 17, 2023. During an interview on 11/023 23 at 10:23 a.m., an administrative staff member (#1) confirmed the Medical Director failed to attend the QAPI meetings held February 16, 2023 and August 17, 2023.