Lutheran Life Villages

dated 9/22/25, indicated the resident had potential to become verbally aggressive.

Interventions included analyzation and documentation of circumstances, triggers and actions known to de-escalate aggressive behavior, assessment of Resident A's coping skills, intervention before agitation escalates and support system and a psychiatric consultation.

Resident A's care plan did not indicate the resident should be monitored when their spouse was present.

The care plan did not indicate staff members were directed to intervene and safeguard the resident if needed.The care plan did not indicate the resident's spouse had given them medication.The care plan did not indicate the resident's spouse had fed the resident.The care plan did not indicate the resident's spouse had repositioned the resident.The care plan did not indicate the resident's spouse had made contact with the resident's face.A unit assignment sheet for direct care staff, (resident profile) dated 8/28/25, provided various categories of care areas for each resident.

Some residents had listed behaviors such as anxiety at times and combativeness with care.

The resident profile indicated Resident A did not have behaviors.

Some residents had listed safety concerns such as fall risk or appropriate footwear.

The resident profile indicated Resident A did not have safety issues as the safety category for Resident A was blank.In an interview, on 10/20/25 at 2:07 PM, Licensed Practical Nurse (LPN) 2 indicated they had been verbally instructed to monitor Resident A when their spouse was present. LPN 2 indicated Resident A's spouse resided at the facility's independent living unit and visited Resident A frequently. LPN 2 indicated Resident A's spouse would get frustrated when the resident got aggressive with them. LPN 2 indicated Resident A's family interactions among the daughter and the spouse were tense.

LPN 2 indicated safety precautions should be included in the residents' care plan. LPN 2 indicated safety precautions should be included on the resident profile assignment sheets.In an interview, on 10/20/25 at 3:05 PM, the Administrator indicated the staff had been given verbal instructions to monitor Resident A's interactions with their spouse.

The Administrator indicated they had been aware of Resident A's spouse giving the resident medication.

The Administrator indicated social services did not have any information due to the Administrator having handled all aspects of the situation and spoke with Resident A's daughter numerous times.

The Administrator indicated they were aware Resident A's care plan and resident profile assignment sheets had not been updated to reflect the recent interactions between Resident A and their spouse.

The Administrator indicated they provided verbal education as the staff do not look at their assignment sheets.

The Administrator indicated they would provide staff education records. An in-service attendance log, dated 10/9/25, and provided by email from the Administrator on 10/21/25 at 7:32 AM was reviewed.

The log indicated verbal education had been provided to staff to monitor Resident A for adverse events when their spouse visits.

The staff members were directed to intervene and safeguard the resident if needed.A current facility policy, dated 4/1/99 and revised on 12/15/22, indicated the facility would identify, correct and intervene in situations where resident abuse is more likely to occur.This citation is related to Intake 26395753.1-27(a)(b)

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