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.

• Actual harm, isolatedF689May 8, 2024

  Based on interview and record review, the facility failed to identify a resident's elopement risk or implement interventions following an elopement for 1 (#31) of 4 residents sampled for elopement, and failed to implement, monitor, and modify fall interventions to prevent multiple falls for 1 (#50) of 6 residents sampled for falls. Findings include: 1. During an interview on 5/8/24 at 12:33 p.m., staff member A stated resident #31 had made some requests to leave the facility to visit his friend. Staff member A stated approximately two or three weeks prior to his elopement, resident #31 had gone to the door to leave, but staff stopped him from exiting. Staff member A stated no elopement assessment had been done, prior to his elopement and he was not identified as an elopement risk. […]

• Actual harm, isolatedF692May 11, 2022

  Based on observation, interview, and record review, the facility failed to identify and implement interventions for a resident's weight loss of 9 percent in 5 months, and a significant weight loss of 6 percent in one month for 1 (#13) of 2 sampled residents. Findings include: During an observation on 5/10/22 at 8:18 a.m., resident #13 was being assisted with his breakfast meal by staff member G. The resident was nonverbal, and not able to eat or drink independently. He refused to eat his scrambled eggs, but did eat his hot cereal. Review of resident #13's Quarterly MDS, with an ARD of 9/7/21, showed a weight of 183 pounds. […]

• No harm, potential for more than minimal, widespreadF640Apr 23, 2025

  Based on interview and record review, the facility failed to ensure MDS assessments were completed, encoded, and transmitted, within the required timeframe, for 1 (#196) of 14 sampled residents, and failed to ensure the assigned staff member had the knowledge necessary to correct MDS transmission errors. The failures resulted in inaccurate and missing MDS data, which was identified during the annual recertification survey process. Findings include: 1. During an interview on [DATE] at 8:15 a.m., staff member D said she did not know how to correct or add a re-entry MDS when a resident returned from the hospital. Staff member D said resident #196 did not have a re-entry MDS and was now due for a quarterly assessment. […]

• No harm, potential for more than minimal, widespreadF801Apr 23, 2025

  Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status, or meal safety for those who consumed food prepared and served by the facility. Findings include: During an observation of the kitchen, on [DATE] at 7:50 a.m., no documentation of advanced training for the dietary manager was posted or readily available. During an interview on [DATE] at 8:00 a.m., staff member E said she had come out of retirement a couple months ago when the dietary manager left. Staff member E said she would help the facility until they could advertise and find a new manager. […]

• No harm, potential for more than minimal, widespreadF812Apr 23, 2025

  Based on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen and the dietary storage areas; failed to ensure kitchen staff labeled and dated food in the coolers; and failed to maintain a clean kitchen environment. The deficient practices increased the risk for the development of foodborne illnesses and unsanitary conditions, for all residents who received food from the kitchen. Findings include: During an observation of the kitchen, during the initial tour on 4/22/25 at 7:25 a.m., the following observations were made: - One pitcher full of fluid was observed in the reach-in cooler. The pitcher was unlabeled and undated. […]