Concordia Lutheran Health and Human Care

In the surveyor’s words

From the most serious findings on record at Concordia Lutheran Health and Human Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 12, 2024

  Based on review of facility policy, clinical records, facility documents, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident. This failure created an immediate jeopardy situation for one of eight residents who were identified as at risk for elopement (Resident R1). Findings include: Review of the facility policy Incidents and Accidents dated 1/16/24, indicated an incident is an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. […]

• No harm, potential for more than minimal, widespreadF812Aug 8, 2025

  Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.A review of facility policy Food Safety and Sanitation dated 1/3/25, indicated all local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department. During an observation on 8/4/25, at 10:55 a.m., of the walk-in cooler in the main kitchen, conducted with Dietary Supervisor (DS) Employee E2, revealed that the cold air condenser unit had a build-up of dust, grime, and dark colored debris around the fan covers and the area of the condenser immediately around the fans. […]

• No harm, potential for more than minimal, widespreadF812Aug 29, 2024

  Based on policy, observations and staff interview, it was determined that the facility failed to properly label food products in the dry storage area and maintain sanitary conditions in the dish room and kitchen which created the potential for cross contamination in the designated main kitchen. Findings include: Review of the facility policy Date Marking for Food Safety dated 1/16/24, indicated the facility adheres to date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety. […]

• No harm, potential for more than minimal, widespreadF812Oct 20, 2023

  Based on facility policy, observations and staff interviews it was determined that the facility failed to maintain sanitary conditions in the dish room which created the potential for cross contamination. (Main Kitchen) Findings include: Review of facility policy Sanitation Inspection dated 1/6/23, indicated all food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. During an observation of dish room on 10/18/23, at 1:15 p.m. it was revealed area above clean side of dish machine area had a build up of a black substance, dirt and grime in the main kitchen. During an interview on 10/18/23, at 1:30 p.m. […]

• No harm, potential for more than minimal, patternF628Aug 8, 2025

  Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for four of six residents sampled with facility-initiated transfers (Residents R11, R42, R143, and R201), and failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for three of six resident hospital transfers (Residents R4, R11, and R143).Findings include: Review of facility policy Transfer and Discharge (including AMA) dated 1/7/25, indicated for a transfer to another provider, for any reason, the following information must be… […]