Lutheran Home

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 19, 2023

  Based on interview, record review, policy review and review of facility documents, the facility failed to ensure two (Residents (R)1 and R3), of ten sampled residents were free of accidents. Specifically, R1 fell to the floor while unsupervised and sustained a fracture requiring surgical intervention, and R3 fell to the floor while unsupervised which resulted in a head laceration requiring medical treatment. In addition, both R1 and R3 were not provided individual interventions on their care plans to prevent the falls from occurring. The failure to provide adequate supervision and individual fall risk interventions placed R1 and R3 at risk for falls with injury. […]

• No harm, potential for more than minimal, widespreadF812Mar 14, 2024

  Based on observations, interviews, and record review the facility did not ensure food was stored and served in accordance with professional standards for food safety. *Staff did not test Sentinel sanitizing solution per manufacturer's instructions when testing the sanitizing sink used for dishwashing. Staff did not log or document testing results. This affected 136 out of 136 residents who receive food prepared by the facility kitchen. *The Unit refrigerator on 2E had multiple food items that were not labeled with resident's name. Open food was not dated. The refrigerator was unclean. There was not a current temperature log posted on the refrigerator and temperatures were not being documented since December of 2023. […]

• No harm, potential for more than minimal, patternF628Jun 10, 2025

  3.) On 2/11/25, the nurses note indicates R54 was experiencing a change in condition and was sent to the hospital. The nurses note on 2/11/25 indicates R54 was being admitted to the facility due to influenza and needing dialysis. On 6/9/25 at 3:10 p.m., during the daily exit meeting with NHA(Nursing Home Administrator)-A and DON (Director of Nursing)-B, Surveyor asked for a copy of the transfer and bedhold notice given to R54 for the 2/11/25 hospitalization. On 6/10/25 Surveyor received the transfer and bedhold notice dated 2/12/25 for R54. The transfer and bedhold notice does not include email address for state agency and facility and does not include information regarding the Ombudsman and how to contact the ombudsman. On 6/10/25 at 10:45 a.m. Surveyor interviewed NHA-A. […]

• No harm, potential for more than minimal, patternF804Jun 10, 2025

  Based on observation, interview, and record review the facility did not ensure each resident receives, and the facility provides food prepared by methods that conserve nutritional value, flavor, and appearance. This deficient practice had the potential to affect 8 residents receiving a puree diet. The recipe for preparing pureed diet was not followed to ensure puree food is prepared by methods that conserve nutritional value, flavor and appearance. Findings include: The facility policy and procedure titled General Food Preparation reviewed 6/2025 documents (in part) . . Policy Statement: All food must be prepared in a manner that maintains its safety, quality, and nutritional value. […]

• No harm, potential for more than minimal, patternF812Jun 10, 2025

  Based on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 3 resident unit refrigerators in the facility. This deficient practice had the potential to affect 46 residents residing on the affected unit. Residents' food stored in the refrigerator was not labeled and/or dated. The refrigerator temperature was not within the recommended temperature for safe food storage. […]