Eben Ezer Lutheran Care Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Smoke Deficiencies

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Services Deficiencies

Have an externally vented heating system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Based on observation and staff interview, it was determined that the facility failed to maintain backflow of the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This was evidenced by the following:1. A current fire suppression backflow report was not provided. The most recent report was 8/24/2023.10.10.2.5.1 The backflow prevention assembly shall be forward flow tested to ensure proper operation. [24:10.10.2.5.1]8.17.4.6* Backflow Devices.8.17.4.6.1* Backflow Prevention Valves.Means shall be provided downstream of all backflow prevention valves for flow tests at system demand.A.8.17.4.6.1 The full flow test .. Based on observation and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105. This was evidenced by the following:1. A current 4-year fire damper inspection report was not provided.NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences.6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency .. Based on observation during the course of the survey it was determined the facility failed to maintain a manual fire alarm box (pull station) in accordance with NFPA 101, 9.6.2.7. This was evidenced by the following:1. Blocked fire alarm pull stations in the Kitchen next to Multipurpose Room, and in Room 543.NFPA 101, Section 9.6.2.7 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance Director at the exit conference. Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. This was evidenced by the following:1. Two fire extinguishers are due for hydro.Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire ExtinguishersThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance Director at .. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is one story, Type V (000), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1970 an upgraded in 2019 and is license for 125 beds. This re-certification survey conducted on August 27, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012).. Through observation and documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by the following:1. A current 5-year internal fire sprinkler inspection report was not provided.2. Loaded sprinkler heads throughout facility. Particularly noted in the Nazareth Dining Room.3. Painted sprinkler heads throughout facility. Particularly noted in Storage Room 644 and Room 609.NFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing..

A recertification survey with complaint #CO37071 and Incident #36591 was completed on 8/12/24 to 8/15/24. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 8/12/24 to 8/15/24. No deficiencies were cited. Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two of four kitchenettes. Specifically, the facility failed to: -Ensure food was labeled, dated and discarded in a timely manner;-Ensure staff performed hand hygiene before donning (putting on) gloves to serve ready-to-eat food; and,-Ensure food was reheated to the appropriate temperature. I. Failed to ensure food was.. Based on observations, record review and interviews, the facility failed to ensure one (#26) of six out of 32 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to: -Ensure the physician' s orders for Resident #26 contained the dose of the medication the nurse was to administer to the resident. Findings include: I. Professional referenceAccording to the National Institutes of Health (NIH), National Libr.. Based on observations, record review and interviews, the facility failed to ensure residents were provided an environment as free of accident hazards as possible for one (#55) of four residents reviewed for accidents and hazards out of 32 sample residents. Specifically, the facility failed to: -Ensure identified interventions were implemented consistently and monitored for effectiveness; and,-Update and revise Resident #55' s care plan with new interventions.. Based on observations, record review and interviews, the facility failed to use a person-centered approach when determining the use of bed rails for one (#57) of 15 residents reviewed for bed rails out of 32 sample residents. Specifically, for Resident #57, the facility failed to:-Assess and review what interventions were attempted prior to the use of side rails; -Ensure the resident' s comprehensive care plan was person centered; -Ensure.. Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for one of five certified nurse aides (CNA) reviewed. Specifically, the facility did not provide regular in-service education based on the outcome of the annual performance review for CNA #5. Findings include: I. Record review CNA #5 (hired befor.. II. Failure to ensure nursing followed proper standards of practice during wound care and followed enhanced barrier precautions appropriately A. Professional referenceCenters for Disease Control and Prevention (4/2/24), Implementation of Personal Protective Equipment (PPE) - Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), was retrieved on 8/19/24 from https://www.cdc.gov/long-term-care-faciliti..