Lutheran Home

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF803Sep 5, 2024

  Based on observation, staff interview, and review of the menu spreadsheets, the facility failed to ensure residents received proper portions of protein and vegetables. This affected all 46 residents in the facility who receive food from the kitchen. Additionally, the facility failed to ensure residents on a pureed diet received proper portions of carbohydrate. This affected six (#2, #7, #19, #20, #32, and #36) residents identified on a pureed diet. The facility census was 46. Findings include: 1. Observation on 09/04/24 at 11:45 A.M. revealed [NAME] #157 taking temperatures of noon menu items. The chicken Philly sandwiches were already prepared with chicken, onion, and peppers portioned into the bun. […]

• No harm, potential for more than minimal, widespreadF868Jun 30, 2022

  Based on staff interview and quarterly quality assessment and assurance (QAA) committee meetings, the facility failed to have a physician attend quarterly QAA committee meetings. This had the potential to affect all 58 residents in the facility. Findings include: Review of the sign-in sheets for the quarterly QAA meetings dated 07/27/21, 12/28/21, 03/29/22, and 06/29/22 revealed the physician was not present during the meetings on 07/27/21 and 12/28/21. Interview on 06/30/22 at 3:52 P.M. with the Administrator confirmed the physician did not attend QAA meetings during the third and fourth quarters of 2021.

• No harm, potential for more than minimal, patternF812Jul 23, 2026

  Based on observation, staff interview, and review of facility policy, the facility failed to ensure food was stored in a sanitary manner. Additionally, the facility failed to ensure the high-temperature dishwasher reached adequate temperatures to ensure disinfection of dishes. Finally, the facility failed to ensure food was served in a sanitary manner. This affected all residents except one (Resident #1) who was identified by the facility as receiving no food by mouth. The facility census was 27.Findings include:1. Observation on 07/20/26 at 7:45 A.M. of the dry storage area of the kitchen revealed a box of sweet potatoes on top of the can storage rack. […]

• No harm, potential for more than minimal, patternF814Jul 23, 2026

  Based on observation and staff interview, the facility failed to ensure kitchen trash were covered. This affected all residents except for one (#1) resident who was identified by the facility as receiving no food by mouth. The facility census was 27.Findings include:Observation on 07/20/26 at 8:05 A.M. of the kitchen area revealed three 30-gallon trash cans without lids. One can was located next to the pot storage and was half full of garbage, one can was located next to the stove and was one-quarter full of garbage, and one can was located by the handwashing station and was one-quarter full of garbage.Interview on 07/20/26 at 8:06 A.M. with Dietary Manager #21 confirmed the trash cans did not have lids on them and they should be covered.Interview on 07/20/26 at 3:20 P.M. […]

• No harm, potential for more than minimal, patternF880Sep 17, 2021

  Based on observation, staff interview, review of a facility policy, review of the Centers for Medicare and Medicaid (CMS) COVID-19 Positivity Rates, and review of the Centers for Disease Control and Prevention (CDC) webpage, the facility failed to ensure staff members were screened for signs and symptoms of COVID-19 upon entering the facility and failed to ensure proper use of personal protective equipment (PPE) while working in a facility located in a county with a high level of COVID-19 positivity testing, to prevent the spread of COVID-19. […]