Lutheran Community Home

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF761Jun 14, 2021

  Based on observation, interview, and record review, the facility failed to store and label medications appropriately in 3 of 4 medication carts and 1 of 3 medication rooms observed. (Medication carts on A, B, and D Hall and B Hall Medication Room) Findings include: 1. During an observation of the A Hall medication cart with RN 2 on [DATE] at 11:29 A.M., There was no open date on an open foil package of [MEDICATION(S)] 0.083% ( a breathing treatment medication) belonging to Resident 78. During an interview on [DATE] at 11:31 A.M., RN 2 indicated if no date was on the package, the medication should be thrown away. She took the one vial of medication and threw it away. 2. […]

• No harm, potential for more than minimal, isolatedF580Dec 5, 2025

  Based on record review and interview, the facility failed to notify the physician and document physician's ongoing guidance for 1 of 19 resident records reviewed for notification of change. (Resident 4) Findings include:The clinical record for Resident 4 was reviewed on 12/03/2025 at 2:33 P.M. An admission Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, fractures of the tibia, hypertension, renal failure, seizure disorder, anxiety, and depression. […]

• No harm, potential for more than minimal, isolatedF583Dec 5, 2025

  Based on observation, record review, and interview, the facility failed to protect residents' personal health information for 2 of 4 observations conducted. Findings included 1. The 200 Hall was observed on 12/04/2025 at 10:23 A.M. Two Medication Carts were sitting in the hallway across from the nurse's station both. Both medication carts were unattended. One Medication Cart had an empty medication card laying on the top labeled with Resident 32's name. The medication was Losartan Potassium 100 milligrams (mg). A second Medication Cart had an empty medication card laying on the top labeled with Resident 40's name. The medication was Losartan HCTZ (Hydrochlorothiazide). No staff members were in the immediate area or near the medication carts. Two unidentified people walked past the cart. […]

• No harm, potential for more than minimal, isolatedF692Dec 5, 2025

  Based on record review and interview, the facility failed to document residents' meal consumption for 3 of 4 residents reviewed for nutrition. (Residents 84, 4, and 72) Findings include: 1.The clinical record for Resident 84 was reviewed on 12/04/2025 at 11:57 A.M. An admission Minimum Data Set (MDS) assessment, dated 11/02/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, expressive language disorder, aphasia (a partial or total loss of language skills due to brain damage), diabetes, and dementia. […]

• No harm, potential for more than minimal, isolatedF755Dec 5, 2025

  Based on record review and interview, the facility failed to provided physician prescribed medications and appropriate dosage for 2 of 19 residents reviewed for pharmacy services. (Residents 4 and 3) Findings include:1.The clinical record for Resident 4 was reviewed on 12/03/2025 at 2:33 P.M. An admission Minimum Data Set (MDS) assessment, dated 10/23/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, fractures of the tibia, hypertension, renal failure, seizure disorder, anxiety, and depression. […]