Lutheran Community Home

Based on record review and interview, the facility failed to notify the physician and document physician's ongoing guidance for 1 of 19 resident records reviewed for notification of change. (Resident 4) Findings include:The clinical record for Resident 4 was reviewed on 12/03/2025 at 2:33 P.M. An admission Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, fractures of the tibia, hypertension, renal failure, seizure disorder, anxiety, and depression. The resident's Electronic Medication Administration Record (EMAR) indicated the resident had the following physician orders:-Daily weight for chronic kidney disease, with a start date of 10/18/2025, and a discontinued date of 10/27/2025, and-Furosemide tablet 40 milligrams (mg), administer 1 tablet, once a day as needed for weight gain of two pounds or more in 24 hours and/or bilateral lower extremity swelling, with a start date of 10/18/2025. The resident did not receive the prescribed, as needed, Furosemide medication 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.

Based on observation, record review, and interview, the facility failed to protect residents' personal health information for 2 of 4 observations conducted. Findings included 1. The 200 Hall was observed on 12/04/2025 at 10:23 A.M. Two Medication Carts were sitting in the hallway across from the nurse's station both. Both medication carts were unattended. One Medication Cart had an empty medication card laying on the top labeled with Resident 32's name. The medication was Losartan Potassium 100 milligrams (mg). A second Medication Cart had an empty medication card laying on the top labeled with Resident 40's name. The medication was Losartan HCTZ (Hydrochlorothiazide). No staff members were in the immediate area or near the medication carts. Two unidentified people walked past the cart. At 10:27 A.M., a staff member took the medication card for Resident 40 from the top of the medication cart, tore the top half of the card off, and disposed of the rest of the card. 2. The 200 Hall was observed on 12/05/2025 at 9:04 A.M. The medication cart was unattended at the time of 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 and interview, the facility failed to document residents' meal consumption for 3 of 4 residents reviewed for nutrition. (Residents 84, 4, and 72) Findings include: 1.The clinical record for Resident 84 was reviewed on 12/04/2025 at 11:57 A.M. An admission Minimum Data Set (MDS) assessment, dated 11/02/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, expressive language disorder, aphasia (a partial or total loss of language skills due to brain damage), diabetes, and dementia. The resident had complaints of pain or difficulty with swallowing or eating and was on a mechanically altered diet. The resident's current Nutritional Status Care Plan indicated she was at risk for impaired nutritional status and listed an Approach to monitor and record meal intakes, with a start date of 10/29/2025. The resident's Meal Consumption Record lacked documentation of meals for the following dates and times: -On 11/03/2025 at breakfast and lunch, -On 11/05/2025 at dinner, -On 11/06/2025 at breakfast and…

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 and interview, the facility failed to provided physician prescribed medications and appropriate dosage for 2 of 19 residents reviewed for pharmacy services. (Residents 4 and 3) Findings include:1.The clinical record for Resident 4 was reviewed on 12/03/2025 at 2:33 P.M. An admission Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, fractures of the tibia, hypertension, renal failure, seizure disorder, anxiety, and depression. The Progress Notes indicated the resident was admitted to the facility on [DATE] at 5:20 P.M. The resident's Electronic Medication Administration Record (EMAR) indicated they did not receive the following prescribed medication; Lacosamide 100 milligrams (mg) for seizures, with a start date of 10/17/2025:s on the following dates and times: -On 10/17/2025 at 7:00 P.M. to 10:00 P.M., due to medication being unavailable. -On 10/18/2025 at 7:00 A.M. to 10:00 A.M.,…

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 and interview, the facility failed to maintain medication storage areas appropriately related to undated medication and a staff member's personal items for 1 of 4 medication carts reviewed (300 Hall Medication Cart), and a resident's personal items for 1 of 3 medication rooms reviewed (300 Hall Medication Room). Findings included:1.Medication storage areas on the 300 Hall were observed on 12/04/2025 at 10:46 A.M., With RN 2, and included, but were not limited to, the following: a. The 300 Hall Medication Cart contained a Lispro insulin pen for Resident 92 that was not labeled with an open date. The RN indicated the pen had not been opened yet, it had been out of the refrigerator since Friday, 11/28/2025, and she would date the pen when she opened it. The pen was good for 28 days. Usually, it was the same day, when a pen was removed from the refrigerator and when it was opened. An insulated coffee cup with a lid was in a drawer of the medication cart sitting next to clean health care supplies. The RN identified the coffee cup as being their own. b. In the 300…

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 update Care Plans related to behaviors and monitoring alert systems for 2 of 3 residents' Care Plans reviewed. (Residents C and D)Findings include:1.The clinical record for Resident C was reviewed on 10/23/2025 at 10:39 A.M. An Annual Minimum Data Set (MDS) assessment, dated 10/03/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, unspecified dementia, anemia, and hypertension. The resident had physical and verbal behavior symptoms for 4 to 6 days of the assessment period. A Progress Note, dated 08/28/2025 at 5:56 P.M., indicated Resident B had wandered into Resident C's bedroom. Resident C had asked the resident to leave and when the other resident did not leave, Resident C smacked at the resident's face. A Progress Note, dated 10/06/2025 at 10:57 A.M., indicated Resident C was stating that another female resident ambulated up to this resident to slap me across the face. Resident C was sitting with staff completing an activity at 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 interview, observation, and record review, the facility failed to provide perineal care in an appropriate manner for a resident with a history of UTIs (Urinary Tract Infections) for 1 of 3 residents reviewed for UTIs. ( Resident 55) Findings include: During an interview on 09/05/24 at 12:55 P.M., Resident 55 indicated she had recently been tested for a UTI and was unsure if the facility had started them on an antibiotic. When being toileted, the resident indicated some of the staff members cleaned them well, and some did not. Morning care for the resident was observed on 09/12/24 at 9:39 A.M. CNA (Certified Nurse Aide) 2 gathered clean linens from a linen closet in a common hallway and entered the resident's room. The CNA assisted the resident from her bed to the bathroom, donned gloves, removed their brief, helped the resident to sit on the toilet, removed her gloves, and gave the resident a moment to use the toilet. The CNA used hand sanitizer then went out into the resident's room to gather clothes for the day and reentered the bathroom. The CNA donned gloves, wet a…

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 and interview, the facility failed to ensure medications were administered as ordered to prevent significant medication errors for 1 of 5 residents reviewed for medications. (Resident 10) Findings include: Resident 10's clinical record was reviewed on 09/13/24 at 10:38 A.M. An Annual MDS (Minimum Data Set) assessment, dated 07/12/24, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, Parkinson's disease, psychotic disorder, epilepsy, and dementia. The resident's February 2024 EMAR (Electronic Medication Administration Record) included, but was not limited to, the following medication orders: - A physician's order, with a start date of 09/28/22 and an end date of 04/29/24, to administer two 50 mg (milligram) chewable phenytoin (an anti-seizure medication) tablets twice a day (once between 7:00 A.M. and 10:00 A.M., and then again between 7:00 P.M. and 10:00 P.M.). - A physician's order, with a start date of 09/28/22 that was discontinued on 02/16/24, to administer one half (25 mg) of a 50 mg chewable…

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 the proper application of an orthotic device for a resident with a contracture (Resident 16) and failed to provide restorative nursing services for residents with limited range of motion (Residents 60 and 64) for 3 of 4 residents reviewed for limited range of motion. Findings include: 1. Resident 16 was observed on 07/18/23 at 11:31 A.M. The resident was in her wheelchair in front of the television. A neck pillow was in place. The resident's right hand was closed as though it was contracted. There was no splint or brace device in use. The resident was observed in her room in bed on 07/18/23 at 2:10 P.M. The resident was awake and moving her thumb and fingers on her left hand. The resident's right hand was closed and there was no splint device in place. The resident was observed in the common area in front of the television on 07/20/23 at 10:30 A.M. A neck pillow was in place. The resident's right hand was closed. The index and middle fingers of the resident's left hand were extended. There was 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.

2. The clinical record for Resident 64 was reviewed on 07/20/23 at 10:25 A.M. A Quarterly MDS assessment, dated 06/07/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, obstructive uropathy, Alzheimer's disease, depression. A Fall Event, dated 06/06/23, indicated the resident had an unwitnessed fall in his room. The resident was sitting on the side of his bed with his breakfast. The resident's legs were wrapped in his blanket, and he was sitting on the floor with his back against the bed. He denied hitting his head and was able to move all extremities. No injuries were noted. An IDT Note, dated 06/06/23 at 4:55 P.M., indicated the resident had a fall on 06/06/23 at 8:30 A.M. An intervention to prevent further falls was to place non-skid strips to the floor of the right side of the bed. The Complete Care Plan was provided by the DON on 07/21/23 at 3:13 P.M. The care plan included, but was not limited to, falls with a start date of 10/24/22. The intervention, with a start date of 06/06/23, indicated 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, interview, and record review, the facility failed to follow appropriate infection control guidelines related to indwelling urinary catheter care for 2 of 3 residents reviewed for urinary catheters and Urinary Tract Infections. (Residents 64 and 76) Findings include: 1. During an observation on 07/19/23 at 10:12 A.M., Resident 64 was at the end of a hallway, sitting in his wheelchair. His indwelling urinary catheter tubing was dragging the floor. During an observation on 07/19/23 at 1:38 P.M., the resident was sitting at the dining room table. The resident's indwelling urinary catheter tubing was resting on the floor. During an observation on 07/20/23 at 1:57 P.M., QMA (Qualified Medication Aide) 12 propelled the resident from the dining room to the common area in front of the TV. The indwelling urinary catheter tubing was dragging the floor. During an observation and interview on 07/24/23 at 11:36 A.M., the resident was sitting in the common area with his indwelling urinary catheter tubing resting on the floor under the resident's foot. QMA 8 indicated 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 observation, interview, and record review, the facility failed to store medications appropriately related following manufacturer's guidelines, labeling medication, and having unsecured loose tablets in the medication carts for 4 of 5 medication carts reviewed. (Medication Carts One and Two on the 100 Hall, and Medication Carts One and Two on the 200 Hall) Findings include: 1. The 100 Hall Medication Carts were observed on 07/18/23 at 10:20 A.M., with RN 2. Cart One contained the following items and loose pills laying in the bottom of drawers: - an Albuterol inhaler with a spacer attached, laying on its side in the bottom drawer for Resident 11, - three small white oval tablets, - one medium white oval tablet, - one small white round tablet, and - one medium pink round tablet. Cart Two contained the following items and loose pills laying in the bottom of drawers: - a Fluticasone inhaler laying on its side in a box for Resident 65, - a box of cornstarch with the top of the box open, the powder cornstarch visible, with a plastic spoon sticking up out of the cornstarch powder…

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 and interview, the facility failed to follow a physician's recommendation related to a urinalysis for 1 of 19 residents reviewed for laboratory services. Findings include: The clinical record for Resident 64 was reviewed on 07/20/23 at 10:25 A.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/07/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, hypertension, obstructive uropathy, Alzheimer's disease, and depression. A Psychiatry Progress Note, dated 06/06/23, indicated the resident was sitting in his room. Per the nursing staff, the resident had not displayed any sadness or tearfulness. He had decreased agitation but continued to to be restless and had multiple falls trying to get up unassisted. The resident had some nights where he was awake and not sleeping. His appetite seemed fair. He was having increased aggression and inappropriate sexual behaviors. The assessment and plan, included but was not limited to, .Recent UTI (Urinary Tract Infection): Recommend rechecking a Urinalysis [UA] to…

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.