Lutheran Hillside Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility failed to de-escalate a resident prior to transfer, investigate incident to identify the root cause and implement interventions to potentially prevent further events for 2 of 3 residents (R1, R3) reviewed for falls in a sample of 4.Findings include:The Event Reporting policy dated 7/29/21 documents an adverse event is defined as an unexpected occurrence which was not expected within normal course of care of disease process and condition of the resident. An adverse event may or may not result in injury and may or may not have resulted from a medical or healthcare error. A witness statement form is used only for witnesses who observed the adverse event. The Administrator, Director of Nursing, Risk Designee and their delegates should conduct investigations. Reporting of abuse/neglect of reasonably suspected resident abuse and/or neglect will be reported to the state agency. 1. R1 was admitted on [DATE] with diagnoses of Hemiplegia following a Cerebral…

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 interview and record review the facility failed to ensure residents were free of abuse/misappropriation of property for three of four residents (R1, R3, and R4) reviewed for theft in the sample of seven. Findings include: Facility Policy/Abuse/Neglect Prevention and Response date 7/29/21 documents: Residents and clients of (the facility) will live and be served in an environment that promotes dignity, respect and strives to be free from abuse, neglect and exploitation. Misappropriation of property is the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 1. Physician Orders indicate R1 was a resident at the facility from 11/15/24 to 12/19/24. Final Report of Financial Abuse dated 12/20/24 indicates that on 12/16/24 R1's credit card numbers were reported as compromised. Report indicates after investigation and video surveillance, evidence led to V7, CNA (Certified Nurse Assistant) as being involved. Report…

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, interview and record review the facility failed to revise care plans for two residents (R5, R7) of three residents reviewed for swallowing difficulties in the sample of seven. Findings include: Facility Policy/Care Planning dated 1/1/23 documents: To ensure that care planning is individualized, interdisciplinary and based on the assessed needs of the patient. The care plan process includes structured assessment and documentation to include: Physical and psychological assessment, which addresses the current disease status, treatment options, functional status, expected prognosis, symptom burden and psychological coping. Care plan changes are based on the evolving needs and preferences of the patient and family over time, recognizing the complex, competing and shifting priorities in goals of care. 1. Nurse Note dated 7/12/24 at 12:10pm indicates R5 had a brief coughing spell at lunch on patty melt. Nurse did pat R5 on the back and remained with her during coughing. Note indicates R5 was encouraged to sip fluid after she was able to get her breath. R5 had no…

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, interview and record review the facility failed to place the facility's annual State Survey Results in a readily accessible location for residents for viewing. This failure has the potential to affect all 69 Residents residing at the facility. Findings include: The facility's Resident Rights Policy, dated 1/30/24 document: Policy Statement: Staff shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of the (facility) community. These rights include the resident's right to: H. Be supported by the (facility) community in exercising their rights; M. Exercise rights not delegated to a legal representative; and W. Examine survey results. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) Form, dated 12/10/24, document 69 residents reside in the facility. On 12/11/24 at 1:00 p m, Residents R2, R6, R22, R25, and R53 attended the Resident Council Meeting. Residents confirmed they did not know where the State…

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, interview, and record review the facility failed to ensure a resident call light was in reach for two (R4 and R12) of 17 residents reviewed for call lights in the sample of 26. Findings include: The facility Call Light Response policy and procedure, dated 1/30/24, documents The policy statement To answer call lights and meet resident need(s) in a timely, dignified, and respectful manner. Call lights will be placed within reach of the resident. 1. On 12/12/24 at 8:15 am, R4 was lying in bed on her back with eyes closed. R4's call light noted resting on the floor behind R4's headboard and out of R4's reach. On 12/12/24 at 2:11 pm, R4 was lying in bed on her back and awake. R4's call light noted resting on the floor behind R4's headboard out of R4's reach. R4 mumbled she is unable to locate her call light. On 12/12/24 at 2:20 pm, V11 CNA (Certified Nursing Assistant) stated R4 has a sensitive touch call light and uses the call light at times. V11 CNA stated R4's call light should not be on the floor behind R4's headboard and should be placed where R4 can reach it.…

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, interview, and record review the facility failed to ensure fall interventions were in place for one (R4) and failed to complete fall risk assessments and root cause analysis for two (R4 and R51) of ten residents reviewed for falls in the sample of 26. Findings include: The facility's Management of Fall Risk policy and procedure, dated 1/30/24, documents Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Each resident will be assessed for the risk factors for falling on admission, quarterly, with change in condition, and upon return from a health care facility. The facility Fall Log, documents R4 had a fall on 8/3/24 at 3:00 am and R51 had falls on 9/2/24 at 1:15 am, 9/27/24 at 6:45 am, and 10/24/24 at 12:30 am. 1. The current Care Plan for R4 documents R4 is at risk for falls and includes the following interventions as: Fall risk assessment to be completed on admission, quarterly,…

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, interview, and record review the facility failed to assess residents for the use of bedrails for two (R26 and R61) of six residents reviewed for bedrails in the sample of 26. Findings include: The facility's Proper Use of Bed Assistive Devices policy and procedure dated 1/30/24, documents The purposes of these guidelines are to ensure the safe use of bed Assistive devices as resident mobility aids and to prohibit the use of bed assistive devices as restraints unless necessary to treat a resident's medical symptoms. Bed assistive devices include side rails, assist rails, and other bed positioning devices. An assessment will be made to determine the resident's symptoms or reason for using the bed assistive device upon initiation, quarterly, and as needed. 1. On 12/10/24 at 10:46 am, there were quarter bed rails noted to each side of R26's bed in the up position. The Bed Assistive Device Assessment's for R26, dated 9/18/24 and 12/7/24 are blank and do not document an assessment having been completed for the use of R26's bed rails. Both assessments document no bed…

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, interview and record review, the facility failed to monitor for identified target behaviors and failed to ensure that identified target behaviors were an indication for the use of an antipsychotic medication for seven of seven residents (R3, R17, R23, R34, R35, R50, and R119) reviewed for psychotropic medications in a sample of 32. Findings include: The facility's Psychotropic Medication Policy, revision date 2/14/20, documents, Residents will not receive psychotropic medications unless behavioral programming and/or environmental changes or other non-pharmacological interventions have failed to sufficiently address the resident's target behavioral goals. If antipsychotic medications are prescribed, documentation will show indication for the medication, attempts to implement care-planned, nonpharmacological approaches and ongoing evaluation of the effectiveness of these interventions. 6. Identified target behaviors will be monitored each shift along with individualized interventions as well as supporting documentation in the clinical record. 1. R3's Electronic…

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, interview and record review, the facility failed to follow a physician's order for wound dressings and treatments, transcribe a physician order's to the order sheet and the treatment administration record, develop a site-specific wound and wound vacuum care plan, revise a pressure ulcer care plan, sanitize scissors before and during pressure ulcer care, and perform hand hygiene and glove change during pressure ulcer care for two of two residents (R43, R60) reviewed for pressure ulcers in the sample of 32. Findings include: The facility's Standard Precautions policy, dated 9/23/22, documents Standard precautions will be used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. This same policy also documents Wash hands after removing gloves. Change gloves, as necessary, during the care of a resident to prevent cross-contamination…

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 interview, observation and record review, the facility failed to ensure a resident with limited range of motion was provided appropriate treatment and services to maintain and/or prevent a further decrease for three of six residents (R4, R43 and R49) reviewed for limited range of motion in the sample of 32. Findings include: 1. R4's current care plan documents the following: R4 has ADL (activities of daily living) self-care deficit, as evidenced by needing assistance with ADL's; weakness in lower extremities. R4's Minimum Data Set Assessment (dated 11/10/22) documents the following in Section G titled 'Functional Limitation in Range of Motion:' R4 has impairment on both sides of her lower extremities. R4's current medical record has no documentation of any type of range of motion program in place. On 01/23/23 at 09:15 AM, R4 was reclined in a recliner with a mechanical lift sling positioned in place underneath her. R4 nodded her head yes when asked is she is a full mechanical lift and when asked if she is unable to stand. On 01/25/23 at 02:15 PM, V2 (Director of Nursing)…

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 interview, observation and record review, the facility failed to ensure an elopement deterrent device was monitored for functionality and placement for one resident (R50) reviewed for wandering/elopement in a sample of 32. Findings include: R50's Wandering/Elopement Risk Assessment (dated 09/20/22) documents R50 is at risk for wandering/elopement, and indicates the following: Elopement deterrent device implemented. R50's current Physician's Orders documents the following order: (Elopement deterrent device) check for functionality and placement every shift and PRN (as needed) placement left ankle. R50's current Care Plan documents the following problem: (R50) has exhibited wandering behavior. This same care plan documents the following intervention: Use (elopement deterrent device). Location: left lower extremity. Monitor every shift and PRN (as needed). On 01/23/23 at 10:15 AM, R50 was sitting in a chair in the sitting area watching television with several other residents sitting nearby. R50 was dressed and groomed and a nearby walker was within her reach. An Elopement…

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, interview and record review the facility failed to complete quarterly side rail assessments for one of one resident (R8) reviewed for side rails in the sample of 32. Findings include: The facility's Proper Use of Bed Assistive Devices policy, dated 9/16/22, documents The purpose of these guidelines are to ensure the safe use of bed assistive devices as resident mobility aides and to prohibit the use of bed assistive devices as restraints unless necessary to treat a resident's medical symptoms. Bed assistive devices include side rails, assist rails, and other bed positioning devices. This policy also documents An assessment will be made to determine the resident's symptoms or reason for using the bed assistive device upon initiation, quarterly and as needed. On 1/25/23 at 11:30 AM, R8's bed had bilateral 1/2 side rails in the upright position. R8's current medical record documents the most recent Bed Assistive Device Assessment was completed on 7/2/22. On 1/26/23 at 11:50 AM, V1 (Administrator) stated she does not have a side rail assessment for R8 since July 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, interview and record review, the facility failed to sanitize scissors before and during wound care, and perform adequate hand hygiene before and during wound care for one of seventeen residents (R60) reviewed for infection control in the sample of 32. Findings include: The facility's Standard Precautions policy, dated 9/23/22, documents Standard precautions will be used in the care of all residents regardless of their diagnosis or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. This same policy also documents Wash hands after removing gloves. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer…

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.