Lutheran Retirement Home

Based on observations, staff interviews, policy review, and the 2022 Food Code of the US Food and Drug Administration the facility failed to prevent the risk of cross contamination to potential bacterial accumulation and spread from jewelry worn while meal prepping and serving in the kitchen. The facility reported a census of 36 residents. Findings include: On initial walk through of the kitchen on 2/23/26 at 10:20 AM observed Staff D, Cook, with multiple rings on 8 of her fingers. On both wrists she wore bracelets while working in the kitchen prepping the meal. On 2/23/26 at 12:20 PM observed Staff D serving the noon meal. She continued to wear the rings on 8 of her fingers and bracelets on both wrists. On 2/24/26 at 11:00 AM observed Staff D pureed pork chops, sweet potatoes, and broccoli for the noon meal. The observation revealed Staff D still wore rings on 8 fingers, with some of her fingers having multiple rings on them. She wore a bracelet on both wrists. On 2/24/26 at 12:00 PM watched Staff D serve the noon meal wearing all the jewelry from the previous observations. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The requirement is not met as evidenced by: Based on clinical record review, staff interview and facility policy, the facility failed to properly assess and provide treatment as ordered to promote healing of, and prevent infection in, existing pressure ulcer for 1of 1 resident reviewed (Resident #12). Resident #12 area started on 9/16/25 and the facility failed to do the treatment as ordered 15 times from 1/27/25 to 2/24/26 in which the area deteriorated.The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers:Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues.Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews the facility failed to provide adequate supervision for a resident identified as a fall risk resulting in an unwitnessed fall in the shower room for 1 of 1 resident reviewed (Resident #13). The facility reported a census of 36 residents. Findings include:Resident #13's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severe cognitive impairment. The MDS indicated Resident #13 needed substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds the trunk or limbs and provides more than half the effort) for transfers and toileting. The MDS further documented the resident had diagnoses of Alzheimer Disease, anxiety, history of falling and unsteady on feet. Resident #13's undated Care Plan documented they had limited physical mobility, unsteadiness on their feet and had a risk for falls. The Care Plan included the following Interventions in place…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility record review, staff interview and policy review, the facility failed to have the minimum required members necessary at the Quality Assessment and Assurance (QAA) meetings to identify issues with respect to which quality assessment and assurance activities. The facility reported a census of 36 residents. Findings include:Review of the facility QAA sign in sheets revealed the July and October 2025 quarterly meetings didn't have the Director of Nursing (DON) present.On 2/26/26 at 11:05 AM the Administrator reported the DON didn't attend the quarterly meetings for July and October because they were gone that day. She reported she didn't try to reschedule the meeting so the DON could attend. The undated facility policy titled Quality Assurance Program documented all staff members of the quality assurance team will meet quarterly with the Medical Director. The policy failed to define the quality assurance team members.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, staff interviews and grievance policy the facility failed to provide prompt effort to resolve a grievance and failed to complete a grievance form related to missing items for 1 of 1 resident reviewed for missing property (Resident #34). The facility reported a census of 36 residents. Findings include: Resident #34's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of debility and cardiorespiratory conditions. On 1/28/25 at 8:50 AM, Resident #34 reported they had a missing black sweatshirt with an emblem that he received from family members prior to his retirement from employment. He added he reported it about three weeks before. He explained he had the same shirt in another color that he showed to the staff so they knew what to look for. He reported he had waited 3 weeks and still didn't have follow up on this from any staff. On 1/29/25 at 10:53 AM Staff G,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews and policy review, the facility failed to follow physician orders to prevent further contractors for 1 of 1 residents reviewed (Resident #19). The facility reported a census of 36 residents. Findings include: Resident #19's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS included diagnoses of joint disorder, depression, arthritis, and anxiety. A Physician Order for Resident #19 dated 9/26/24 included the following orders: a. Palm grip to right hand at all times when in bed to prevent contractors b. Tubi grip to left hand daily to reduce moisture and prevent injury from her nails digging into her palm. Change on shower days and as needed (PRN). Resident #19's clinical record lacked documentation of notification with the physician on not doing the treatment nor that they voiced pain while providing the treatment order for their hands. The Plan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, resident, and staff interview, the facility failed to ensure a resident received dental services for 1 of 1 Resident's (Resident #20) reviewed for dental services. The facility reported a census of 36 residents. Findings include: Resident #20's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included a diagnosis of dental caries (cavities). The Interdisciplinary Progress Note dated 2/22/22 at 1:58 PM documented on admission, Resident #20 didn't have any missing or broken teeth. The Care Plan Intervention initiated 5/19/22 directed to refer to professions as needed (PRN), if indicated by Primary Care Physician (PCP), or Psych services. Arrange for appointments with PCP, dental, eye professionals, and podiatrist, per government regulation, family, and at Resident #20's request. Resident #20's Medical Diagnosis included a diagnosis dated 7/29/22 of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy and procedure review, and staff interviews the facility failed to recognize a resident as a victim prior to transferring them to a different unit, instead of their alleged abuser for 1 of 5 residents reviewed (Resident #1). It can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm (e.g., embarrassment, punishment, humiliation, anxiety) as a result of having to move after getting violated by another resident. The facility identified a census of 36 residents. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. Resident #1 required total assistance with toileting hygiene and transfers. Resident #1 didn't walk and used a wheelchair for mobility. The MDS included diagnoses of Alzheimer's disease, and non-Alzheimer's dementia. The Communication - with Family Note dated 4/15/24 at 1:49…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.