Faith Lutheran Home

In the surveyor’s words

From the most serious findings on record at Faith Lutheran Home, in the surveyor’s own words.

• Immediate jeopardy, patternF700Jun 17, 2021

  Based on observations, staff interviews, clinical record review, policy review, and the United States Food & Drug Administration's Guide, the facility failed to assess for initial medical need and risk of entrapment of bed rails for 4 of 14 residents (#17, #27, #28, #36) and maintain ongoing bed rail evaluations for 14 of 14 residents (#8, #13, #17, #18, #19,#20, #24, #25, #27, #28, #29, #30, #32, #36); obtain consent with education of possible risk of entrapment for 6 of 14 residents (#8, #17, #18, #20, #27, #36), and the entrapment of a resident (#27) between the side rail and mattress, all of which resulted in an immediate jeopardy and could lead to serious injury, impairment, or death. The facility reported a census of residents 33. Findings include: 1. […]

• No harm, potential for more than minimal, patternF805Jul 16, 2025

  Based on observation, document review, menu review, policy review and staff interview the facility failed to properly prepare pureed food to ensure each resident received the appropriate serving size and nutrients for 7 of 7 residents sampled (Residents #2, #4, #7, #17, #19, #20, and #37). The facility reported a census of 39 residents.Findings include:On 7/14/25 the Certified Dietary Manager (CDM) provided an untitled document with a list of residents who received a pureed diet. The list included Residents #2, #4, #7, #17, #19, #20 and #37.A Week 2, Tuesday Noon Meal Puree Menu documented the following:a. Beef cube pepper steak pureed serving #8 scoop (4 ounces (oz))b. French onion rice, #8 scoopc. […]

• No harm, potential for more than minimal, patternF880Jun 17, 2021

  Based on review of infection prevention policies and procedures, staff interviews, observations, and review of hand washing policy, the facility failed to maintain infection prevention policy containing documents for transmission based precautions, antibiotic stewardship and other facility policy and procedures. During a dining observation staff failed to wash their hands appropriately. At the time of the survey, the facility reported a census of 33 residents. Resource: Centers for Disease Control and Prevention. (2021, January 8). Healthcare Providers. Centers for Disease Control and Prevention. https://www.cdc.gov/handhygiene/providers/index.html. Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF812Jul 16, 2025

  Based on observation, policy review, 2022 United States (US) Food and Drug Administration (FDA) Food Code, consulting Dietitian and staff interviews, the facility failed to prevent soiled gloves from coming into contact with food during the food preparation for 4 of 4 residents (Resident #14, #23, #34 and #39). The facility reported a census of 39 residents.Findings include: On 7/15/25 observed the following during the kitchen service:At 11:28 AM without completing hand hygiene, Staff A, Cook, placed the blade into the food processor with her bare right hand, she used to touch multiple other surfaces prior to touching the food processor blade. […]

• No harm, potential for more than minimal, isolatedF688Jan 12, 2023

  Based on observation, clinical record review and staff interview the facility failed to provide the therapy recommended restorative program to prevent potential decline for 2 of 3 residents (Resident #14 and #30) sampled. The facility identified a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #14 with a long/short term memory impairment and severely impaired decision making ability. The Resident required total assistance with bed mobility, transfer, dressing, toileting and personal hygiene. […]