Eben Ezer Lutheran Care Center-Ii

A revisit survey was completed on 4/16/25 for all previous deficiencies cited on 8/14/24. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey was completed on 8/14/24. Deficiencies were cited. Based on observation, interview, and record review, the residence failed to ensure care plans detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs, affecting two of three sample residents (#2, #3). Findings include:1. Resident #3 was admitted to the residence on 4/3/21.The record for Resident #3 contained no active care plan.On 8/14/24 at approximately 8:30 a.m., Staff #2 prepared and administered medications to Resident #3.On 8/14/24 at 10:10 a.m., the administrator said the residence did not have a care plan completed for Resident #3.On 8/14/23 at approximately 3:00 p.m., the nurse manager acknowledged there was no care plan in Resident #3' s record. She also stated the resident was at risk for falls and staff administere.. Based on record review and interview the residence failed to ensure at least one staff member onsite at all times with Cardiopulmonary Resuscitation certification training from a nationally recognized organization or meeting the curriculum requirements, affecting 14 current residents.Findings include:Documented CPR certification for Staff #1 and #4 revealed a CPR completion date of 4/23/23 and 5/7/24 respectively. However, the certification was not from a nationally recognized organization or meeting minimum curriculum requirements.The staff schedule from 7/1/24 to 8/14/24 revealed the following shifts had no staff members onsite with current certification in CPR from a nationally recognized organization:2:00 p.m. to 10:00 p.m. on 7/1, 7/3, 7/5, 7/6, 7/7, 7/6, 7/18, 7/20-7/22, 8/1210:00 p.m. t.. Based on record review and interview, the residence failed to have readily available a roster of current residents along with a residence diagram showing room locations, affecting 14 current residents. Findings include:On 8/14/24 at 7:10 a.m., Staff #2 was asked to provide the resident roster. Staff #2 provided a one page document that listed resident names and room numbers. The document did not include emergency contact information or a residence diagram showing room locations.On 8/14/24 at 7:30 a.m., the chief financial officer was asked to provide the resident roster that the residence would take with them in an emergency situation if evacuation was required. At approximately 10:00 a.m., the chief executive officer (CEO) was asked to provide the resident roster that the residence would take .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.3 If the assisted living residence becomes aware of information that indicates a current administrator, individual appointed as an interim administrator, staff member, or volunteer could pose a risk to the health, safety, and welfare of the residents and/or that such individual is not of good, moral, and responsible character, the assisted living residence shall request an updated criminal history and adult protective services record check for such individual from the CBI and/or other relevant law enforcement agency.7.13 Each personnel file shall i..