Eben Ezer Lutheran Care Center Jay Drive #2

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 11 current residents.Findings include:1. Record ReviewDocumentation of CPR certification for Staff #6 revealed that the staff had CPR certification; however, it was not from a nationally recognized organization.The July and August 2024 staff schedules revealed the residence did not ensure there was at least one staff member with current CPR certification from a nationally recognized organization for 32 overnight shifts.2. InterviewOn 8/28/24 at 9:15 a.m., the administrator acknowledged that Staff #6 certification from a web-based CPR training and did not comply with the current requirement. 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 out of one residents.Specifically, the residence failed to ensure that Resident #2 was without restraint as she had a bed rail that prevented her from safely and independently getting out of bed. Subsequently, Resident #2 climbed over the bed rail, fell, and sustained two skin tears. Documention revealed that Resident #2 stated several times that her hip hurt. Findings include:1. Residence PolicyThe residence' s undated resident agreement read in part that the residence was not designed for the use of restrictive egress alert devices and did not admit individuals in need of such devices.2. ObservationOn 8/27/24 at 11:43 a.m., Resident #2' s bed had a bed rail and a mattress alarm.3. Record reviewAn incident report, dated 7/29/24 at 11:45 p.m., read in part that staff found Resident #2 on the floor with two skin tears. Resident #2 stated several ti.. Based on observation, record review and interview, the residence failed to report to the department that they exceeded the licensed capacity, affecting 11 current residents.Findings include:On 8/27/24 at approximately 8:15 a.m., the residence had 11 beds and 11 residents. On 8/26/24, a review of Department records revealed that the residence was licensed for an occupancy of 10 rooms. On 8/27/24 at approximately 8:45 a.m., the residence ' s roster revealed that there were 11 beds and 11 residents.3. InterviewOn 8/28/24 at approximately 9:15 a.m., the administrator stated that she did not know that the residence exceeded their licensed capacity.

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 or controlled egress measures that restricted the member (resident) were used affecting one current resident (#2).Specifically, the residence failed to ensure that Resident #2 was without restraint as she had a bed rail that prevented her from safely and independently getting out of bed. Subsequently, Resident #2 climbed over the bed rail, fell, and sustained two skin tears. Documention revealed that Resident #2 stated several times that her hip hurt. Findings include:1. Residence PolicyThe residence' s undated resident agreement read in part that the residence was not designed for the use of restrictive egress alert devices and did not admit individuals in need of such devices.2. ObservationOn 8/27/24 at 11:43 a.m., Resident #2' s bed had a bed rail and a mattress alarm.3. Record reviewAn incident report, dated 7/29/24 at 11:45 p.m., read in part that staff found Resident #2 on the floor with two skin tears. Resident #2 stated several times that her hip hurt. Staff were concerned that she was in pain and called the administrator to see if they should send her to the emergency department.An incident report, dated 8/8/24 at 3:05 a.m., read in part that Resident #2 climbed over the bed rail and fell to the floor. Furthermore, the staff documented that she put her in bed three times and she continued to climb the bed rail.4. InterviewsOn 8/27/24 at approximately 9:15 a.m., Staff #4 expressed concern about Resident #2 due to a recent increase in falls. Staff #4 reported that Resident #2 attempted to climb over the bed rail at night, raising concerns about the potential for another serious injury.On 8/27/24 at 10:20 a.m., a family member of Resident #2 stated that the bedrail was the cause of the two skin tears and severe hip pain that the resident sustained on 7/29/24. She also stated that Reident #2 was unable to get out of bed due to the bed rails so she tried to climb over them. The family member also said that on 8/30/24 aro..