Inspection Report
Follow-Up
Census: 79
Capacity: 95
Deficiencies: 0
Nov 4, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/24/24 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR to the Life Safety Code survey, Lutheran Community Home was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) and 410 IAC 16.2. The facility consists of two one-story buildings, both fully sprinkled except for a detached storage building.
Report Facts
Facility capacity: 95
Census: 79
Building capacity: 85
Building census: 72
Building capacity: 10
Building census: 7
Inspection Report
Annual Inspection
Census: 78
Capacity: 95
Deficiencies: 6
Sep 24, 2024
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including failure to maintain documentation for battery-operated smoke alarms, failure to perform semi-annual visual inspections of the fire alarm system, corrosion on sprinkler heads, outdated sprinkler gauges, and lack of GFCI protection on an electrical receptacle near a sink.
Severity Breakdown
SS=F: 5
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure documentation for preventative maintenance of battery-operated smoke alarms for 5 of 12 months. | SS=F |
| Failed to ensure battery replacement documentation for battery-operated smoke alarms. | SS=F |
| Failed to maintain fire alarm system with required semi-annual visual inspections. | SS=F |
| Failed to replace sprinkler heads covered with corrosion in the kitchen dishwashing area. | SS=F |
| Failed to replace or test sprinkler system gauges every 5 years; gauges were outdated. | SS=F |
| Failed to provide ground fault circuit interrupter (GFCI) protection on an electrical receptacle within 3 feet of a sink in the D Wing Clean Utility Room. | SS=D |
Report Facts
Certified beds: 95
Census: 78
Months without smoke alarm maintenance documentation: 5
Sprinkler gauges: 3
Sprinkler heads: 2
Inspection Report
Annual Inspection
Census: 29
Capacity: 108
Deficiencies: 2
Sep 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and the Investigation of Complaint IN00440204. The visit included a State Residential Licensure Survey.
Findings
No deficiencies were cited related to the complaint allegations. Two deficiencies were cited: one for failure to provide appropriate perineal care to a resident with a history of UTIs, and another for failure to ensure medications were administered as ordered to prevent significant medication errors for a resident.
Complaint Details
Complaint IN00440204 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide perineal care in an appropriate manner for a resident with a history of UTIs. | SS=D |
| Failed to ensure medications were administered as ordered to prevent significant medication errors for a resident. | SS=D |
Report Facts
Survey dates: 7
Census Bed Type - SNF/NF: 79
Census Bed Type - Residential: 29
Total Capacity: 108
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 26
Total Census Payor: 79
Medication doses: 75
Medication doses: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karyn Fleetwood | Executive Director | Signed the report |
| RN 3 | Registered Nurse | Interviewed regarding resident's UTIs and antibiotic treatment |
| CNA 2 | Certified Nurse Aide | Observed providing perineal care and interviewed about care procedures |
| ADON | Assistant Director of Nursing | Interviewed regarding medication order clarification |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 13, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Lutheran Community Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 76
Capacity: 103
Deficiencies: 0
Jan 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00423292.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00423292 was investigated and found to have no deficiencies related to the allegations.
Report Facts
SNF/NF census: 76
Residential census: 27
Total capacity: 103
Medicare census: 6
Medicaid census: 47
Other payor census: 23
Total census: 76
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 15, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Lutheran Community Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 78
Capacity: 116
Deficiencies: 4
Aug 7, 2023
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including lint accumulation in laundry dryer air intakes, malfunctioning emergency lighting, failure of a hazardous area door to self-close and latch, and improper use of flexible cords and power strips instead of fixed wiring.
Deficiencies (4)
| Description |
|---|
| Laundry area dryer room air intakes were substantially covered with dryer lint, posing a fire hazard. |
| Two battery operated emergency lights failed to function during testing. |
| The corridor door to the Soiled Utility room near the C Wing nurse's station failed to self-close and latch properly. |
| Flexible cords were used as a substitute for fixed wiring, including a refrigerator powered by a power strip. |
Report Facts
Certified beds: 116
Census: 78
Battery operated emergency lights failed: 2
Hazardous areas observed: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karyn Fleetwood | Executive Director | Named in relation to findings and exit conference. |
| Maintenance Supervisor | Named in relation to findings and exit conference but no full name provided. |
Inspection Report
Annual Inspection
Census: 29
Capacity: 106
Deficiencies: 5
Jul 25, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted on July 18, 19, 20, 21, 24, and 25, 2023.
Findings
The facility was found to have multiple deficiencies including failure to ensure proper application of orthotic devices and restorative nursing services for residents with limited range of motion, failure to follow care plan interventions related to falls, failure to follow infection control guidelines related to indwelling urinary catheter care, failure to store medications appropriately, and failure to follow physician recommendations related to laboratory services.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure proper application of orthotic devices and restorative nursing services for residents with limited range of motion. | SS=D |
| Failure to follow care plan interventions related to falls for 2 of 5 residents reviewed. | SS=D |
| Failure to follow appropriate infection control guidelines related to indwelling urinary catheter care for 2 of 3 residents reviewed. | SS=D |
| Failure to store medications appropriately related to following manufacturer's guidelines, labeling medication, and having unsecured loose tablets in medication carts for 4 of 5 medication carts reviewed. | SS=D |
| Failure to follow a physician's recommendation related to a urinalysis for 1 of 19 residents reviewed for laboratory services. | SS=D |
Report Facts
Survey dates: 6
Census SNF/NF beds: 77
Census Residential beds: 29
Total licensed capacity: 106
Residents with orthotic/restorative programs: Logs created and updated monthly for residents requiring orthotics and restorative programs
Dates lacking documentation: 19
Residents reviewed for accidents: 5
Residents reviewed for urinary catheters: 3
Medication carts reviewed: 5
Residents reviewed for laboratory services: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karyn Fleetwood | Executive Director | Signed the report on 08/07/2023 |
| RN 10 | Registered Nurse | Provided instructions for orthotic device for Resident 16 |
| CNA 11 | Certified Nurse Aide | Applied splint device to Resident 16 and documented orthotic use |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding fall care plan interventions and catheter care |
| RN 5 | Registered Nurse | Observed catheter bag placement and assisted Resident 64 |
| CNA 4 | Certified Nurse Aide | Assisted Resident 64 with mechanical lift |
| QMA 3 | Qualified Medication Aide | Observed medication carts and storage practices |
| QMA 12 | Qualified Medication Aide | Observed Resident 64 catheter tubing dragging on floor |
| QMA 8 | Qualified Medication Aide | Observed Resident 64 catheter tubing on floor |
| ADON | Assistant Director of Nursing | Provided information on medication cart audits |
| DON | Director of Nursing | Provided policies and interviews regarding laboratory services and plan of correction |
Inspection Report
Life Safety
Deficiencies: 0
Jul 25, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 07/25/23 was completed on 08/24/23.
Findings
Lutheran Community Home was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 20, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00403708 completed on March 21, 2023.
Findings
Lutheran Community Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00403708 completed with paper compliance review; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 111
Capacity: 111
Deficiencies: 1
Mar 21, 2023
Visit Reason
This visit was for the investigation of Complaint IN00403708 related to allegations of deficient care regarding bowel/bladder incontinence, catheter use, and urinary tract infections.
Findings
The facility failed to provide appropriate care and services related to perineal care for incontinence, use of a bedpan, and hand hygiene for 2 of 6 residents reviewed, contributing to urinary tract infections. Observations revealed improper glove use and hand hygiene by staff during care. Laboratory reports confirmed 4 of 6 residents had E-coli infections. The facility implemented re-education and competency checks to address these deficiencies.
Complaint Details
Complaint IN00403708 was substantiated with a Federal/State deficiency cited at F690 related to bowel/bladder incontinence, catheter use, and urinary tract infections.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate care and services related to perineal care for incontinence, use of a bedpan, and hand hygiene for 2 of 6 residents reviewed related to urinary tract infections. | SS=D |
Report Facts
Census: 111
Licensed Capacity: 111
Residents with recent UTIs: 6
Residents with E-coli positive cultures: 4
Residents reviewed for bowel and bladder care: 6
Residents affected by deficient care: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Karyn Fleetwood | Executive Director | Signed the report |
| CNA 2 | Certified Nursing Aide | Named in observation of deficient perineal care and hand hygiene |
| QMA 3 | Qualified Medication Assistant | Named in observation of deficient perineal care and hand hygiene |
| RN 4 | Registered Nurse | Observed during care with QMA 3 |
| ADON | Assistant Director of Nursing | Provided information on residents with UTIs and facility policy |
Inspection Report
Complaint Investigation
Census: 81
Capacity: 105
Deficiencies: 0
Jan 3, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00398213 and IN00393653.
Findings
Complaint IN00398213 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00393653 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00398213 - Substantiated with no deficiencies cited. Complaint IN00393653 - Unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF beds: 81
Census Residential beds: 24
Total Census: 105
Census Payor Medicare: 10
Census Payor Medicaid: 43
Census Payor Other: 28
Total Census Payor: 81
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 21, 2022
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on July 25, 2022.
Findings
Lutheran Community Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Deficiencies: 0
Aug 25, 2022
Visit Reason
The visit was conducted for the Life Safety Code Recertification and State Licensure Survey, as well as the Emergency Preparedness Survey.
Findings
Lutheran Community Home was found in compliance with the Emergency Preparedness Requirements and Life Safety Code requirements, including Medicare/Medicaid participation regulations and the 2012 Edition of the NFPA 101 Life Safety Code.
Report Facts
Facility Number: 347
Provider Number: 155715
AIM Number: 100275440
Inspection Report
Life Safety
Census: 77
Capacity: 116
Deficiencies: 14
Aug 25, 2022
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 Edition of NFPA 101, Life Safety Code.
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency power system testing, means of egress obstructions, emergency lighting documentation, sprinkler system maintenance, portable fire extinguisher inspections, smoke barrier penetrations, fire door inspections, and electrical equipment use. Deficiencies affected resident safety and fire protection systems.
Severity Breakdown
SS=F: 7
SS=E: 5
SS=C: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; missing 36-month four-hour load test documentation for emergency generator. | SS=F |
| Failed to maintain means of egress free from obstructions; two large upholstered chairs and a wheeled weigh scale blocked corridors. | SS=E |
| Failed to document monthly testing duration for all battery backup emergency lights. | SS=C |
| Failed to maintain ceiling construction in HVAC room; holes and penetrations in suspended ceiling tiles. | SS=E |
| Portable fire extinguisher freestanding on floor, not securely installed. | SS=F |
| Therapy room corridor door propped open, failing to resist passage of smoke. | SS=E |
| Corridor door to therapy room propped open with wedge, impeding closing and latching. | SS=E |
| Openings through ceiling smoke barrier not protected; large HVAC duct penetrated smoke barrier. | SS=E |
| Smoke barrier door had holes above and below door handle, compromising smoke resistance. | SS=E |
| Failed to ensure annual inspection and testing of all fire door assemblies; some fire doors not included in inspection documentation. | SS=F |
| Fire-rated door to oxygen storage room missing bottom hinge causing holes in door frame and door. | SS=F |
| Failed to document 36-month emergency generator testing for four continuous hours. | SS=F |
| Extension cords and power strips used as substitutes for fixed wiring in patient care vicinity. | SS=E |
| Portable fire extinguishers missing monthly inspection documentation for multiple months. | SS=F |
Report Facts
Certified beds: 116
Census: 77
Emergency generator rating: 154
Portable fire extinguishers: 68
Oxygen cylinders: 56
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