Inspection Reports for
Lutheran Living Senior Campus

The visit was complaint-related, investigating multiple complaints and facility reported incidents. Complaints #1746946-C, #1746954-C, and #2574374-C resulted in deficiencies. The facility reported incident #2573332-I also resulted in a deficiency.

The facility was found deficient in multiple areas including failure to conduct quarterly Care Conferences for residents, failure to provide timely physician and family notifications for significant changes or incidents, failure to provide proper discharge notices, failure to perform behavioral health assessments, and inadequate supervision and care leading to a resident's suicide. The facility also failed to follow proper staffing and notification protocols.

The complaint investigation was substantiated. The facility failed to conduct required care conferences, timely notify physician and family of wounds, correctly cite discharge regulations, provide timely wound care, and provide adequate behavioral health care and supervision, resulting in a resident suicide. Immediate Jeopardy was identified and later removed after corrective actions were implemented.

The facility failed to conduct quarterly Care Conferences for one resident, failed to notify physician and family timely about a new wound, issued an involuntary discharge notice citing incorrect state regulations, failed to provide timely wound care interventions, and failed to provide adequate behavioral health care and supervision for a resident with a history of depression and suicidal ideation, resulting in the resident's suicide during a period without 1:1 supervision.

Complaint #126730-C was substantiated based on clinical record review, legal guardian interview, and staff interviews indicating failure to notify the resident's guardian promptly after a fall on 2/13/25.

The complaint #126730-C was substantiated. The facility failed to notify the resident's guardian in a timely manner after a fall resulting in injury and transfer to the hospital for one of three residents reviewed. The facility has developed and implemented a plan of correction to ensure compliance with notification requirements and prevent future similar incidents.

The complaint investigation found that the facility did not promptly notify Resident #1's legal guardian after a fall on 2/13/25 that resulted in injury and hospital transfer. The guardian was unaware of the incident until the following day. The facility had an after-hours on-call number that was not used. The guardian confirmed ongoing concerns about timely notification.

The facility failed to promptly notify the legal guardian of Resident #1's fall and subsequent hospital transfer. The guardian was only made aware the following day despite an after-hours on-call number being available. The Assistant Director of Nursing took corrective action by posting bright yellow cards with the on-call number and process at each nurse's station.

The facility was found deficient in multiple areas including failure to report an alleged abuse incident, failure to notify the Ombudsman of resident transfers, failure to meet professional standards for lab testing, failure to properly store medications, and failure to maintain proper food temperatures. The facility has plans to educate staff and implement corrective actions to address these deficiencies.

The complaint investigation involved allegations of failure to report abuse, failure to notify the Ombudsman of hospital transfers, failure to obtain ordered lab tests, medication storage issues, and food temperature concerns. The abuse allegation was investigated and found to be unsubstantiated due to the resident's history of false accusations and no physical findings. Ombudsman notifications were not documented for hospital transfers. The lab order for hemoglobin A1c was missed. Medication cart was observed unlocked. Food temperatures were below acceptable levels during meal service.

The facility failed to timely report an alleged abuse incident involving Resident #52, failed to notify the Ombudsman of hospital transfers for Residents #37 and #110, failed to obtain a hemoglobin A1c lab for Resident #35 as ordered, failed to keep one medication cart locked when not in use, and failed to serve food at appropriate temperatures during one dinner meal and for room trays on the 600 Hall.

Complaints #123343-C, #123555-C, #123698-C and Facility Reported Incidents #122565-I, #123211-I and #123388-I were substantiated.

The facility failed to notify a resident's physician upon discovering a positive COVID infection, failed to provide incontinence care according to professional standards, and failed to properly identify residents prior to medication administration leading to medication errors. Additionally, the facility failed to ensure adequate supervision to prevent resident elopement and maintain safety. Corrective actions and education plans were implemented with compliance audits scheduled.

The facility was found deficient in multiple areas including failure to notify a physician of a positive COVID-19 case, inadequate incontinence care, medication administration errors, and failure to prevent a resident with exit-seeking behavior from leaving the facility unsupervised. Immediate jeopardy was identified related to resident elopement but was removed after corrective actions.

The investigation was triggered by complaints #118707-C, #119722-C, #120233-C, #120962-C, and #121833-C. Complaint #120233-C was substantiated. The Immediate Jeopardy began on February 11, 2024, when Resident #1 was found unresponsive and deceased. The facility removed the Immediate Jeopardy on July 26, 2024 after implementing corrective actions.

The facility failed to provide adequate staff and supervision to assist a resident who called out for help in a timely manner, resulting in the resident being found unresponsive and deceased. The investigation revealed severe staffing shortages on the night of the incident, inadequate response to staffing calls, and failure of the Assistant Director of Nursing to fulfill on-call responsibilities.

The complaint investigation substantiated Immediate Jeopardy beginning February 11, 2024, when Resident #1 was found unresponsive after calling out for help and staff delayed response for up to 10 minutes. The facility was short staffed that night, and the Assistant Director of Nursing failed to respond to calls for assistance. A written reprimand was issued to the Assistant Director of Nursing for failure to fulfill on-call responsibilities.

The facility failed to provide adequate staff and supervision to assist Resident #1 in a timely manner, resulting in the resident being found face down and unresponsive. The investigation revealed severe cognitive impairment of the resident, staffing shortages during the night shift, and failure of on-call staff to respond adequately. Immediate Jeopardy was identified and later removed after corrective actions were implemented.

The complaint investigation was initiated due to multiple allegations including resident abuse by staff, failure to protect resident dignity, inconsistent documentation of advance directives, failure to notify family and physicians of incidents, inadequate staffing, and failure to prevent accidents and injuries. The investigation revealed substantiated abuse and neglect, failure to report and investigate allegations timely, and multiple care and safety deficiencies.

The facility was found deficient in multiple areas including failure to protect residents' dignity and privacy, inconsistent documentation and communication of advance directives, failure to notify family and physicians of incidents, resident-to-resident abuse, inadequate investigation of abuse allegations, insufficient staffing, incomplete care plans, failure to prevent catheter bags from touching the floor, and failure to maintain a functioning call light system. Several residents experienced falls, injuries, and inadequate care due to these deficiencies.

The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, inconsistent documentation of advance directives, failure to notify family or POA of incidents, inadequate transfer documentation, incomplete care plans and care conferences, failure to provide scheduled showers, insufficient staffing leading to unmet resident needs, inadequate supervision resulting in falls and injuries, and lack of accessible functioning call systems for residents.

The facility had multiple deficiencies including failure to ensure resident dignity, inconsistent documentation of advance directives, failure to notify family of abuse allegations, failure to protect residents from abuse and neglect, inadequate investigation of abuse allegations, incomplete care plans and care conferences, insufficient staffing, failure to prevent catheter bags from touching the floor, inadequate supervision to prevent accidents, failure to complete PASARR resubmissions, failure to provide timely baseline care plans, failure to provide showers as scheduled, failure to assess and treat wounds and pain, failure to post nurse staffing information, failure to implement non-pharmacological interventions prior to psychotropic medication administration, and employment of staff without current certification.

The investigation was triggered by complaints #108012-C, #109452-C, #112427-C and facility reported incidents #105513-I, #108639-I, #112190-I, and #112547-I. Complaint #112427-C and incidents #105513-I and #112547-I were substantiated.

The facility was found to be in compliance with COVID-19 infection control practices. However, deficiencies were identified including failure to notify the physician of a resident's change in condition (Resident #8) and failure to ensure resident safety to prevent undetected elopement of a cognitively impaired resident (Resident #1) from a locked unit.

The complaint investigation found that Resident #8's physician was not notified timely of the resident's orthostatic hypotension until 4/19/23, despite earlier signs and staff awareness. Resident #1 eloped from a secured dementia unit on 6/30/22 without staff knowledge due to door alarms that only sounded briefly and staff not hearing alarms. The resident was found outside by a contractor and returned safely. Staff interviews confirmed lack of alarm notification and supervision.

The facility failed to notify the physician timely about Resident #8's orthostatic hypotension and failed to perform appropriate assessments. Additionally, the facility failed to prevent the undetected elopement of Resident #1 from a locked CCDI Unit due to malfunctioning door alarms and inadequate supervision.

The complaint investigation revealed that Resident #8's physician was not notified timely of the resident's orthostatic hypotension until 4/19/23, despite earlier signs and therapy notes indicating the condition. Resident #1 eloped from the secured CCDI unit on 6/30/22 through a fire exit door with malfunctioning alarms that only sounded briefly, and staff were unaware of the elopement until a contractor found the resident outside.

The facility failed to notify the physician timely about Resident #8's orthostatic hypotension and did not perform appropriate assessments. Additionally, the facility failed to prevent the elopement of Resident #1 from a locked CCDI unit due to malfunctioning door alarms and inadequate supervision.

Complaints #100894-C and #103891-C were substantiated. Complaints #102289-C and #103938-C were not substantiated. Facility-reported incident #104410-I was substantiated.

The survey identified multiple deficiencies including failure to report injuries of unknown origin, failure to notify the Ombudsman of hospital transfers, failure to provide bed hold policy upon hospital transfer, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, failure to assess skin under splints, unsafe resident transfers, improper catheter care, incorrect diet portioning, and infection control violations related to COVID-19 positive staff working and inadequate PPE use during tracheostomy care.

The facility was found deficient in multiple areas including failure to timely report injuries of unknown origin, failure to notify the Ombudsman of hospitalizations, failure to provide bed hold policy notifications, inaccurate MDS assessments, incomplete care plans, unsafe resident transfers, improper catheter care, incorrect dietary portioning for pureed diets, and inadequate infection control practices including allowing symptomatic COVID-positive staff to work and failure to use appropriate PPE during tracheostomy care.

Complaints #95320, #95317 and Facility Self-Reported Incident #95321 were substantiated. The incident involved Staff A verbally abusing Resident #1 on 1/15/21, witnessed by another CNA and the resident's family member. Staff A was found to have a history of complaints regarding disrespectful behavior.

The facility was found compliant with COVID-19 infection control practices. However, complaints and a self-reported incident were substantiated involving Staff A verbally abusing Resident #1 during medication administration, failing to treat the resident with dignity and respect. Multiple staff and family member statements confirmed the verbal abuse incident.