Inspection·December 12, 2019

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents were equipped with appropriately assessed wheelchairs. This affected one (Resident #44) of 26 residents reviewed for the provision of assistive devices. The facility census was 107. Residents Affected - Few Findings include: Resident #44 admitted to the facility on [DATE] with the diagnoses including, multiple sclerosis, hypertension, pulmonary hypertension, osteoarthritis, asthma, morbid obesity, and vitamin D deficiency. According to the Minimum Data Set (MDS) assessment dated [DATE] identified the resident as alert and oriented. The resident required extensive physical assistance of one staff for the completion of activities of daily living, and utilized a wheelchair for mobility. Review of the care plan for potential for falls related to impaired balance during transition, dated 10/29/19, revealed an intervention to encourage the use of a wheelchair and refer to the basic needs and preferences care plan for mobility assistance needs. On 10/29/19, a plan of care was initiated to address the risk for impaired skin integrity related to restricted mobility, multiple sclerosis, and confined to a bed/chair majority of time. Interventions included the use of a pressure reducing cushion. During observation on 12/10/19 at 8:02 A.M., Resident #44 was in the main dining room sitting at a table. No cushion was observed to the seat. Further observation located the wheelchair seat cushion in the residents room. At 10:45 A.M. the resident was propelling herself in the hall without a wheelchair cushion in place. During interview on 12/10/19 at 1:30 P.M. Resident #44 stated she removes the cushion from the wheelchair because her feet won't reach the floor when the cushion is in place. The resident also indicated the width of the chair was narrow and this made it difficult to access the wheels to propel herself. During interview on 12/11/19 at 8:10 A.M., the Director of Nursing (DON) verified the resident's wheelchair was not an appropriate fit and that the resident was removing the seat cushion to propel herself. The DON was unable to provide documentation indicating an assessment was completed to address the current fit of the wheelchair. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 366192 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366192 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lutheran Village at Wolfcreek 2001 Perrysburg Holland Road Holland, OH 43528 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)