Lutheran Village at Wolfcreek

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF761Sep 8, 2025

  Based on observation, staff interview, review of a medication expiration list, review of a medication package insert, and review of a facility policy, the facility failed to ensure medications and biologicals were properly dated and discarded after expiration. This had the potential to affect all 57 residents in the facility. The facility census was 57.Findings include:Observation on [DATE] at 9:08 A.M. of the medication storage room with Registered Nurse (RN) #682 revealed a bottle of Geri-Lanta (an oral medication to relieve symptoms of excess stomach acid and gas) on the shelf. The bottle was opened with an expiration date of [DATE]. […]

• No harm, potential for more than minimal, widespreadF880Mar 4, 2021

  Based on review of the facility census, observation, staff interview and policy review, the facility failed to ensure staff utilized personal protective equipment (PPE) according to their policy for droplet isolation and had PPE readily available for use. This affected 10 residents (#09, #13, #15, #18, #24, #36, #42, #54, #66, and #79) of 10 reviewed for droplet isolation. This had the potential to affect all residents in the facility. The facility census was 82. Findings include: Review of the facility census with admission summary revealed Resident #09 was admitted on [DATE], Resident #13 was admitted on [DATE], Resident #15 was admitted on [DATE], Resident #18 was admitted on [DATE], Resident #24 was admitted on [DATE], Resident #36 was admitted on [DATE], Resident #42 was admitted on… […]

• No harm, potential for more than minimal, patternF695Sep 8, 2025

  Based on observation, resident interview, staff interview, medical record review, and review of facility policy, the facility failed to ensure oxygen tubing was changed and labeled as required, and failed to ensure oxygen was administered at the appropriate rate as ordered. This affected four (#20, #12, #21, and #39) of six residents reviewed for oxygen therapy. The facility census was 57. Findings Include: 1. Review of Resident #20's medical record revealed an admission date of 03/21/24. […]

• No harm, potential for more than minimal, patternF880Sep 8, 2025

  Based on observation, staff interview, medical record review, review of manufacture instructions, review of a facility medication guide, and review of facility policies, the facility failed to ensure staff wore appropriate personal protective equipment when providing care for residents on enhanced barrier precautions, failed to ensure medical equipment was properly sanitized between resident use, failed to ensure hand hygiene was performed during resident care, and failed to an insulin pen was sanitized prior to applying a needle for administration. This affected four (#41, #19, #23, and #1) of four residents reviewed for infection control measured during resident care. The census was 57. Findings include: 1. […]

• No harm, potential for more than minimal, patternF812Apr 13, 2023

  Based on observations, staff interview, review of sanitizer log and policy review, the facility failed to ensure foods were stored in a safe and sanitary manner. In addition, the facility failed to ensure the chemical dish washing machine had the proper chemical sanitizer level for effective disinfection of dishes and utensils. This had the potential to affect 52 residents who receive food from the kitchen. Three residents (#37, #43 and #53) received no food by mouth and thus no food from the kitchen. The facility census was 55. Findings include: Observation on 04/10/23 at 8:43 A.M., of main kitchen's walk-in cooler found a ten inch by twelve inches by six-inch-deep steam table tray full of meatballs in a red sauce on a wheeled cart in line for use. […]