Eben Ezer Lutheran Care Center Jay Drive #1

A relicensure survey was completed on 8/28/24. Deficiencies were cited. Based on interview and record review the residence failed to ensure there was at least one staff member on-site at all times with current certification in cardiopulmonary resuscitation (CPR) from a nationally recognized organization affecting nine current residents.Findings include:1. Record ReviewThe July 2024 staff schedule, time cards and CPR certifications revealed the overnight shift had two shifts that were not covered by at least one staff member who certified in CPR onsite at all times. The August 2024 staff schedule , time cards and CPR certifications revealed the overnight shift had two shifts that were not covered by at least one staff member who were certified in CPR onsite at all times.2. InterviewOn 8/28/24 at 9:15 a.m., the administrator acknowledged that the online CPR training did not comply with the current regulations but claimed that the staff who completed the online training also participated in the skills portion. However, she was unable to provide documentation to support this. Based on observation, record review and interview, the residence failed not to use restraints of any kind and deprive a resident of their liberty for the purposes of care, affecting one of two sample residents.Findings include:1. Resident Agreement The sample Resident Agreement, undated, read in part that the residency was not designed for the use of restrictive egress alert devices or admitting individuals who were in need of such devices.2. ObservationOn 8/27/24 at 11:43 a.m., Resident #2 had a recliner with a chair alarm. When Resident #2 would get up from the recliner, an alarm would sound. The resident could not turn the alarm off by herself.3. Record reviewAn undated care plan for Resident #2, read in part, the residence used video monitoring to mitigate the risks of the resident ambulating alone. However, it failed to include information about the recliner equipped with an alarm. 4. InterviewOn 8/28/24 at approximately 10:00 a.m., the administrator initially indicated she was unaware that chair alarms were in violation of state regulations. However, she later acknowledged that an alarm was a restraint to residents.

A recertification survey was completed on 8/28/24. A deficiency was cited. Based on observation, record review, and interview, the facility (residence) failed to ensure that no restrictive devices or approaches that have the effect of restricting members (residents) of any kind were used, such as silent or auditory alarms, affecting one out of two residents.Findings include:1. Resident Agreement The sample Resident Agreement, undated, read in part that the residency was not designed for the use of restrictive egress alert devices or admitting individuals who were in need of such devices.2. ObservationOn 8/27/24 at 11:43 a.m., Resident #2 had a recliner with a chair alarm. When Resident #2 would get up from the recliner, an alarm would sound. The resident could not turn the alarm off by herself.3. Record reviewAn undated care plan for Resident #2, read in part, the residence used video monitoring to mitigate the risks of the resident ambulating alone. However, it failed to include information about the recliner equipped with an alarm. 4. InterviewOn 8/28/24 at approximately 10:00 a.m., the administrator initially indicated she was unaware that chair alarms were in violation of state regulations. However, she later acknowledged that an alarm was a restraint to residents.