The Vinton Lutheran Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interview, and facility policy review the facility failed to keep a resident's care plan updated for falls for 1 of 3 residents reviewed. The facility reported a census of 47 residents.Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 admitted to the facility on [DATE]. The MDS identified the resident with diagnoses which included fractured right pubis (pelvis bone), diabetes, obesity and kidney failure. The resident required substantial assistance from staff to complete activities of daily living. He required substantial assistance for showering, standing and toileting, and used a walker or wheelchair to move about. The resident had a Brief Interview for Mental Status score of 12/15 which indicated the resident had moderate cognitive impairment, and had a fall in the last month prior to admission, entry, or reentry. Review of the resident's progress notes revealed the following falls: a. On 11/15/25 at 6:30 am, the staff found the resident…

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 observation, staff interview, and policy review, the facility failed to ensure proper food handling practices and further failed to ensure the kitchen and equipment was kept clean and sanitary to reduce the risk of contamination and food-borne illness. The facility reported a census of 47 residents. Findings include: On 4/7/25 at 9:55 AM during the initial tour of the facility kitchen, the following sanitation concerns were noted relating to the potential risk of contamination and food-borne illness: a. The walk-in cooler was noted to have 2 large trays of white rice on a shelf at the back of the cooler that were not covered or dated. b. The 2 large trays of white rice were located in the walk-in cooler on a shelf beneath a ham covered with plastic wrap, a large beef roast in a plastic cover and roast beef slices in a foil pan. c. The walk-in freezer was noted to have a plastic tub of chicken pot pie filling with the plastic wrap pulled back and the chicken pot pie filling exposed to the cold with frost/ice covering the top of it. On 4/7/25 at 9:55 AM during the initial…

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 record review, staff interview, and policy review, the facility failed to ensure a psychotropic medication (a medication that affects a person's mental state) gradual dose reduction (GDR) was attempted or declined with a physician rational for 2 of 4 residents reviewed (Resident #19 and #25). The facility reported a census of 47 Residents. Findings included: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #25 revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. It included diagnoses of Alzheimer's disease, heart failure, depression, dementia, diabetes, hypertension, sleep apnea, and anxiety disorder. It also revealed the resident was independent with eating, toileting, personal hygiene, and transfers but required moderate assistance with bathing. The Electronic Health Record (EHR) included physician's orders for: a) Seroquel 12.5 milligrams (mg) daily related to Alzheimer's disease with late onset b) Sertraline 50 mg; give 1.5 tabs (75…

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, record review, staff interview, and policy review, the facility failed to document oxygen tubing changes as ordered to protect against potential infections for 1 of 1 residents reviewed on oxygen (Resident #2). The facility reported a census of 47 residents. Findings Include: The Annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS revealed resident's diagnoses included fibromyalgia, anxiety, venous insufficiency, atrial fibrillation, heart failure, acute embolism and thrombosis, pulmonary hypertension, myocardial infarction, dyspnea (shortness of breath), pneumonia, and dependence on supplemental oxygen. The resident was coded as independent for eating, and requiring maximal staff assistance for toileting, bathing, personal hygiene, and transfers. The MDS documented resident was short of breath with exertion and used oxygen. In an observation on 4/8/25 at 1:41 PM, an…

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, staff and resident interviews, and observations the facility failed to follow their policy and procedures regarding intravenous therapy for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 44 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had diagnoses which included pneumonia, septicemia, and diabetes mellitus. The resident had a Brief Interview for Mental Status score of 13 out of 15, which indicated she had intact cognitive ability. The resident received daily antibiotics via a peripheral inserted central catheter (PICC line). Review of the Care Plan dated 10/17/24 informed the staff the resident had dehydration and required fluid maintenance related to pneumonia. The Care Plan directed the staff to administer intravenous antibiotic therapy once daily for severe sepsis. Review of a Progress Note dated 11/3/24 at 9:00 pm revealed Staff E-RN attempted 3 times to place a peripheral intravenous line in…

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 observation, record review, interview, and facility policy review the facility failed to take a resident to the restroom timely to prevent his brief from soiling his clothing for 1 of 3 residents reviewed (Resident #46). The facility further failed to ensure resident's fingernails were cleaned and trimmed for 1 of 3 residents reviewed (Resident #21). The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #46 dated 3/28/24 included diagnoses of non-Alzheimer's dementia and anxiety. The Brief Interview for Mental Status (BIMS) documented a score of 1, which indicated severe cognitive impairment. It documented the need for substantial/maximal assistance with toileting with the helper completing more than half of the effort. The Care Plan focus area for Resident #46, initiated 9/27/23, documented he was at risk for pressure ulcer/skin breakdown related to frequent urine incontinence. A section titled falls documented risk related to incontinence. An area titled ADL (Activities of Daily Living) function noted the…

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 record review, resident interview, and staff interview the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for 1 of 1 residents reviewed (Resident #8). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS listed diagnoses of Anxiety Disorder, Depression, and Bipolar Disorder. A document with a mailing date of 6/28/19 titled Status Change Review Outcome documented a current PASRR Level II Summary of Finding report, dated 4/30/19 remained valid for the resident's nursing facility stay. The summary report on Page 6 revealed the resident was approved for 150 days of nursing facility care. The facility lacked documentation that a follow up PASRR was completed. On 04/15/24 at 10:38 AM the resident stated she lived here because of her mental illness. She could do a lot of things independently but needed…

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, and staff interviews, the facility failed to reassess the effectiveness of fall interventions and to modify the resident's care plan to meet the resident's needs for 1 of 1 Residents reviewed (Resident #4). The Care Plan failed to identify specific staff interventions to mitigate future falls. The facility reported a census of 50 residents. Findings include: The re-admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 identified a Brief Interview for Mental Status (BIMS ) score of 10 which indicated moderate cognitive impairment. The MDS documented the resident had diagnoses of fracture of left femur, cancer, arthritis, osteoporosis, and malnutrition. The MDS documented the resident required substantial/maximal assistance for mobility and walking was not attempted due to medical condition or safety concerns. The Care Plan initiated 4/24/14 with a target date of 4/10/24 identified the resident at risk for falls. The Care Plan informed staff the…

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 record review, interviews, and policy review the facility failed to notify the pharmacist of a resident's admission in a timely manner to complete a drug regimen review (DRR) for 1 of 5 residents reviewed for unnecessary medications (Resident #33). The facility reported a census of 50 residents. Findings include: The MDS for Resident #33 dated 4/1/24 revealed diagnoses of anxiety disorder, depression, and diabetes mellitus II. The entry MDS was dated 11/6/23 and the Medicare 5 day admission MDS was dated 11/13/23. The Medication Administration Record (MAR) documented escitalopram Oxalate 20 mg for depression (11/7/23) and buspirone HCl 10 mg for anxiety (12/6/23). A document titled Doctor's Order Sheet, dated 11/6/23 at 9:00 AM, documented medications were listed on the resident's transfer sheet and was signed by the resident's provider. A document titled Order Summary Report from the resident's prior facility, dated 11/2/23 at 11:53 AM, revealed the resident was prescribed 24 medications at the time of the transfer to this facility. Each page was signed by the Director 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.

Based on observation, policy review, and staff interview, the facility failed to ensure they were not serving expired food items to reduce the risk of contamination and food-borne illness. The facility reported a census of 50 residents. Findings include: On 4/15/24 at 9:16 AM, the initial tour of the facility kitchen with the Dining Services Director (DSM), revealed the following: a. 5 unopened boxes of fudge cream icing mix with an expiration date of 1/18/24 b. 2 unopened boxes of cinnamon streusel topping mix with an expiration date of 1/4/24 c. 1 unopened box of cinnamon streusel topping mix with an expiration date of 1/14/24 d. 10 cans of evaporated milk with an expiration date of 3/28/24 e. 1 opened box of grape nuts cereal with a resident's name on it and an expiration date of 1/1/23 f. 1 unopened box of grape nuts cereal with an expiration date of 2/23/24 g. 12 unopened quart containers of half and half with an expiration date of 3/28/24 h. 2 unopened containers of whipping cream with an expiration date of 3/31/24 i. 1 unopened container and 1 opened container of whipping…

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 reviews, staff and resident interviews and observations the facility failed to report an allegation of abuse within 24 hours or the next business day for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 50. Findings include: According to the Minimum Data Set, dated [DATE], Resident #1 had a Brief Interview for Mental Status score of 11 out of 15 which indicated moderate cognitive impairment. The resident required limited assistance of 1 staff for transfers, ambulation and hygiene. The resident had diagnoses which included hemiplegia, history of fractured left femur, history of falls and syncope. Review of the resident's Care Plan dated 1/6/22 informed the staff the resident is hard of hearing and wears hearing aides, to assist with activities of daily living and ambulate with assistance of 1 staff with the use of a front wheeled walker. Review of a State Agency (SA) intake form, Resident #1 reported to Staff A-Certified Nurses Aide on 3/24/23 that on the…

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.