Lutheran Village at Wolf Creek

Based on personnel file review and staff interview, the facility failed to ensure staff were trained by a registered nurse (RN) or licensed practical nurse (LPN) under the direction of an RN. This had the potential to affect all 51 residents in the facility. The census was 51. Findings include: Review of the personnel file for Resident Assistant (RA) #101 revealed a hire date of 02/05/24. Interview on 11/12/24 at 2:46 P.M. with the Clinical Manager (CM) and concurrent review of a document titled, Resident Aide Skills Demonstration ChecklistBased on personnel file review and staff interview, the facility failed to ensure staff were trained by a registered nurse (RN) or licensed practical nurse (LPN) under the direction of an RN. This had the potential to affect all 51 residents in the facility. The census was 51.

Findings include:

Review of the personnel file for Resident Assistant (RA) #101 revealed a hire date of 02/05/24.

Interview on 11/12/24 at 2:46 P.M. with the Clinical Manager (CM) and concurrent review of a document titled, Resident Aide Skills Demonstration Checklist

Based on observation, staff interview, and medical record review, the facility failed to ensure medications were appropriately labeled and stored in a safe manner. This affected three (#14, #35, and #64) of three residents reviewed for medication storage. The facility census was 51.

Findings include:

1. Review of the medical record for Resident #14 revealed an admission date of 01/01/18 with a diagnosis of hypertension.

Review of a current physician order, reviewed 09/27/24, revealed Resident #14 received the medication to treat low blood pressure midodrine hydrochloride (HCl) with instructions to take one tablet by mouth three times daily as needed.

Observation and interview on 11/12/24 at 8:38 A.M. with Licensed Practical Nurse (LPN) #201 of the medication cart revealed nine cards of midodrine HCl for Resident #14. Eight of the cards contained 10 tablets and one of the cards contained nine tablets. LPN #201 confirmed the expiration date for each card of midodrine HCl was 09/14/24.

2. Review of the medical record for Resident #35 revealed an admission date of 07/01/24 with a diagnosis of type II diabetes mellitus.

Review of the physician order dated 07/02/24 revealed Resident #35 received Liraglutide (an injectable anti-diabetic medication) once daily.

Review of the medical record for Resident #64 revealed an admission date of 10/25/24 with a diagnosis of type II diabetes mellitus.

Review of the current physician order signed 10/31/24 revealed Resident #64 received Basaglar (long-acting injectable insulin) once daily.

Observation on 11/12/24 at 4:44 P.M. revealed Resident #35 had two insulin pens in one compartment of the medication cart. One pen was labeled with Resident #35's name and the other was not. Further observation revealed an insulin pen in a compartment with a glucometer bag with Resident #64's name on it. The insulin pen was not labeled with Resident #64's name. Concurrent interview with LPN #202 confirmed the insulin pens for Resident #35 and Resident #64 were not labeled with the resident's names.

This violation is a recite to the annual survey completed 04/13/23.

Based on review of the resident trust accounts, review of resident trust authorization (RTAs) documents, and staff interview, the facility failed to ensure residents signed an RTA prior to the facility managing their money and failed to ensure RTAs were witnessed as required. This affected three (#32, #35, and #58) of five residents reviewed for resident trust accounts. The facility census was 51.

Findings include:

Review of the resident trust account statements dated 11/12/24 revealed Resident #32, Resident #35, and Resident #58 had current balances in their resident trust accounts.

Interview on 11/12/24 at 4:26 P.M. with the Administrator revealed no RTAs were signed by Resident #32 or Resident #35. The Administrator confirmed an RTA gave the facility authority to manage resident funds, and further confirmed Resident #32 and Resident #35 currently had funds managed by the facility. Continued interview with the Administrator confirmed the RTA form for Resident #58 was signed by Resident #58's responsible party, but the signature was not witnessed, and the Administrator confirmed a witness was required on the form.

Based on veterinary record review, staff interview, and review of the facility policy, the facility failed to ensure pets in the facility received annual physical examinations. This affected one (#14) of two residents reviewed for pets. The facility census was 51. Findings include: Review of the veterinary record dated 11/12/24 for Resident #14's cat revealed the cat was last seen by the veterinarian for a physical exam on 09/18/23. Interview on 11/12/24 at approximately 5:00 P.M. with the Clinical Manager confirmed the facility could provide no evidence Resident #14's cat received an annual physical exam since 09/18/23. Review of the policy titled, Pet PolicyBased on veterinary record review, staff interview, and review of the facility policy, the facility failed to ensure pets in the facility received annual physical examinations. This affected one (#14) of two residents reviewed for pets. The facility census was 51.

Findings include:

Review of the veterinary record dated 11/12/24 for Resident #14's cat revealed the cat was last seen by the veterinarian for a physical exam on 09/18/23.

Interview on 11/12/24 at approximately 5:00 P.M. with the Clinical Manager confirmed the facility could provide no evidence Resident #14's cat received an annual physical exam since 09/18/23.

Review of the policy titled, Pet Policy

Based on observation, staff interview, review of the dishwasher temperature logs, and review of the facility policies, the facility failed to ensure a low-temperature dishwasher was accurately monitored for temperature and sanitation level. Additionally, the facility failed to ensure staff practiced appropriate hand hygiene during meal service. This had the potential to affect all 51 residents in the facility. The census was 51. Findings include: 1. Observation on 11/12/24 at 9:20 A.M. revealed the facility's dishwasher was a low-temperature dishwasher. The dishwasher relied on chlorine to sanitize dishes. Observation on 11/12/24 at 9:21 A.M. with Dietary Manager (DM) #301, during a wash and rinse cycle of the dishwasher, revealed a wash temperature of 95 degrees Fahrenheit (F) and a rinse temperature of 110 degrees F. Concurrent interview with DM #301 revealed the wash and rinse temperatures were appropriate. Further observation and interview with DM #301 of the manufacturer's label attached to the dishwasher revealed the minimum wash and rinse temperatures should be 120 degrees F. Continued observation of a second wash and rinse cycle of the dishwasher revealed a wash temperature of 108 degrees F and a rinse temperature of 120 degrees F. Continued observation revealed DM #301 using quaternary ammonium solution test strips to test the sanitation level of the dishwasher rinse cycle. Observation and interview with DM #301 revealed the sanitizer used in the dishwasher was sodium hypochlorite and required a different type of test strip to determine the sanitation level of the dishwasher. Interview on 11/12/24 at 11:52 A.M. with DM #301 and concurrent review of the dish machine temperature log for November 2024 revealed staff were documenting wash temperatures between 140 degrees F and 148 degrees F, and rinse temperatures between 180 degrees F to 189 degrees F. Further review of the temperature log revealed the bottom of the form indicated, Wash = 140 degrees, Rinse = 180 degrees. DM #301 confirmed the facility's dishwasher was not reaching temperatures of 140 to 180 degrees F and indicated the temperature log was designed for high-temperature dishwasher. DM #301 further confirmed the facility did not have a high-temperature dishwasher. DM #301 additionally confirmed the log contained no documentation of the concentration of the chlorine solution required to ensure dishes were sanitized after washing. Review of the policy titled, Sanitation Procedure - Dish machine Temperature LogBased on observation, staff interview, review of the dishwasher temperature logs, and review of the facility policies, the facility failed to ensure a low-temperature dishwasher was accurately monitored for temperature and sanitation level. Additionally, the facility failed to ensure staff practiced appropriate hand hygiene during meal service. This had the potential to affect all 51 residents in the facility. The census was 51.

Findings include:

1. Observation on 11/12/24 at 9:20 A.M. revealed the facility's dishwasher was a low-temperature dishwasher. The dishwasher relied on chlorine to sanitize dishes.

Observation on 11/12/24 at 9:21 A.M. with Dietary Manager (DM) #301, during a wash and rinse cycle of the dishwasher, revealed a wash temperature of 95 degrees Fahrenheit (F) and a rinse temperature of 110 degrees F. Concurrent interview with DM #301 revealed the wash and rinse temperatures were appropriate. Further observation and interview with DM #301 of the manufacturer's label attached to the dishwasher revealed the minimum wash and rinse temperatures should be 120 degrees F. Continued observation of a second wash and rinse cycle of the dishwasher revealed a wash temperature of 108 degrees F and a rinse temperature of 120 degrees F.

Continued observation revealed DM #301 using quaternary ammonium solution test strips to test the sanitation level of the dishwasher rinse cycle. Observation and interview with DM #301 revealed the sanitizer used in the dishwasher was sodium hypochlorite and required a different type of test strip to determine the sanitation level of the dishwasher.

Interview on 11/12/24 at 11:52 A.M. with DM #301 and concurrent review of the dish machine temperature log for November 2024 revealed staff were documenting wash temperatures between 140 degrees F and 148 degrees F, and rinse temperatures between 180 degrees F to 189 degrees F. Further review of the temperature log revealed the bottom of the form indicated, Wash = 140 degrees, Rinse = 180 degrees. DM #301 confirmed the facility's dishwasher was not reaching temperatures of 140 to 180 degrees F and indicated the temperature log was designed for high-temperature dishwasher. DM #301 further confirmed the facility did not have a high-temperature dishwasher. DM #301 additionally confirmed the log contained no documentation of the concentration of the chlorine solution required to ensure dishes were sanitized after washing.

Review of the policy titled, Sanitation Procedure - Dish machine Temperature Log

Based on observation, record review, staff interview, and review of the policy, the facility failed to ensure insulin pens were dated upon opening. This affected three (#101, #102, and #103) of three residents reviewed for dated insulin pens. The facility census was 57

Findings include:

1. Review of the medical record for Resident #101 revealed an admission date of 07/28/22 with a diagnosis of type 2 diabetes mellitus.

Review of the current physician orders for April 2023 revealed Resident #101 received Novolog sliding scale insulin before meals (three times) daily, and Lantus long-acting insulin once daily.

Observation on 04/13/23 at approximately 11:15 A.M., revealed Licensed Practical Nurse (LPN) #501 injecting Resident #101 with an insulin pen. Observation of the Novolog flexpen (short-acting insulin) revealed Resident #501's name was written on the lid of the pen. No additional personal information was on the pen. No date was written on the insulin pen to indicate when the pen was opened.

Continued observation revealed Resident #501 also had a Lantus long-acting insulin pen which also had only her name written on the lid, and no date the pen was opened.

Interview on 04/13/23 at approximately 11:17 A.M. with LPN #501 confirmed both insulin pens for Resident #501 did not have a date they were opened.

2. Review of the medical record for Resident #102 revealed an admission date of 01/02/18 with a diagnosis of type 2 diabetes mellitus.

Review of the physician order dated March 2023 revealed Resident #102 received Novolog sliding scale insulin twice daily.

Observation on 04/13/23 at approximately 11:20 A.M., of the insulin pens for Resident #102 revealed a Novolog short acting insulin pen with only Resident #102's name written on the lid. No date was written to indicate when the pen was opened.

3. Review of the medical record for Resident #103 revealed an admission date of 06/01/22 with a diagnosis of type 2 diabetes mellitus.

Review of the current physician orders for April 2023 revealed Resident #103 received Novolog sliding scale short-acting insulin three times daily, and receive Lantus long-acting insulin once daily.

Continued observation on 04/13/23 at approximately 11:20 A.M., of the insulin pens for Resident #103 revealed a Novolog short acting insulin pen and a Lantus long-acting insulin pen with only Resident #103's name written on the lid. No date was written to indicate when the pens were opened.

Interview on 04/13/23 at approximately 11:20 A.M., with LPN #500 confirmed the insulin pens for Resident #102 and Resident #103 were undated. Further, LPN #500 stated the insulin pens should be dated upon opening and were good for 28 days after opening. LPN #500 could not determine when the insulin pens for Resident #102 and Resident #103 were opened.

Continued interview and observation with LPN #500 on 04/13/23 at approximately 11:20 A.M., revealed the long-acting insulin pen for Resident #102 was filled at the pharmacy in February 2023. LPN #500 could not find when the pens for Residents #101 and #103 were filled by the pharmacy.

Interview on 04/13/23 at 11:23 A.M. with the Clinical Manager #1 verified insulin pens should be dated upon opening.

Review of the facility policy Medication Administration

Based on observations, staff interview, sanitizer log review, 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 residents 52 residents who receive food from the kitchen, excluding three residents (#37, #43 and #53) who receive 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 inch by six inch deep steam table tray full of meatballs in a red sauce on a wheeled cart in line for use. The dated marked was 03/30/23, eleven days prior.

Interview on 04/10/23 at 8:46 A.M., with Dietary Staff (DS) #662 verified the date on the meatballs was the use by date and they should have been thrown away and not in line for use.

Observation on 04/10/23 at 8:50 A.M., of the dry storage area found a one gallon jug of soy sauce open and partially used on the dry storage shelf. The label on the soy sauce read Refrigerate After Opening.

Interview on 04/10/23 at 8:51 A.M., with DS #655 verified the gallon jug of soy sauce was open, approximately 1/4 of it was used and it was stored in the dry storage area and was not refrigerated as it should have been. DS #655 stated it would be thrown out.

Observation on 04/10/23 at 8:55 A.M., of the dishwashing machine found it was a low temperature chemical machine. Observations of the chemicals connected to the machine found two dishwashing detergents and a rinse solution. No sanitizer was found.

Observation on 04/10/23 at 9:02 A.M., of DS #655 completing a chemical test strip found the sanitizer level was zero. Coinciding interview with DS #655 verified the white five gallon jug contained dish soap, the one gallon pink jug contained dish soap, the blue one gallon jug contained a rinsing agent and there was no sanitizer connected to the dishwasher. DS #655 reported he was not sure how long there was no sanitizer connected to the machine but there should have been.

Interview on 04/10/23 at 9:06 A.M., with Dietary Manager (DM) #606 verified there was a mix up with the chemicals and there should have been a dish soap and a sanitizer not two dish soaps connected to the machine. DM #606 stated they would have the dishwashing machine repair person come out today and correct the machine. While they waited they would wash in the three sink system and provided disposable items.

Observation on 04/11/23 at 7:28 A.M., of the dishwasher in the main kitchen found a yellow one gallon jug of sanitizer, a pink one gallon jug of dish soap, and a blue one gallon of jug of rinse agent connected to the dishwashing machine. Coinciding interview with DS #655 verified the machine maintenance company came out yesterday and corrected the issue. DS #655 verified the issue was the white five gallon bucket was dish soap and was supposed to be the yellow sanitizer. They had been running two dish soaps and no sanitizer.

Review of the Facility's Dish Machine Chlorine Sanitizer Log revealed in March 2023 only one A.M. chlorine level was taken and the last P.M. level taken was on 03/24/23. There were no sanitizer level tests logged from 03/25/23 to 04/10/23.

Review of the facility policy titled, Food Storage revised March 2022 revealed left over food was to be used within seven days or discarded.