Lutheran Home at Topton, The

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF684Sep 18, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure physicians' orders were implemented for two of 21 sampled residents. (Residents 8, 10)Findings include: Clinical record review revealed that Resident 8 had diagnoses that included congestive heart failure and hypertension (high blood pressure). On November 21, 2024, a physician ordered that staff weigh the resident daily because of her congestive heart failure. There was no documented evidence that staff weighed the resident on August 12 and 20, and September 2, 4, 12, 14, and 16, 2025. Clinical record review revealed that Resident 10 had diagnoses that included heart failure and atrial fibrillation (irregular heart rhythm). […]

• No harm, potential for more than minimal, isolatedF880Sep 18, 2025

  Based on a review of employee personnel files and staff interviews, it was determined that the facility failed to follow Centers for Disease Control and Prevention (CDC) recommendations for baseline tuberculosis (TB) screening and testing for three of five newly hired employees. (Employee 2, 3, and 5)Findings include: According to the CDC's recommendations entitled, Baseline Tuberculosis Screening and Testing for Health Care Personnel, last updated December 19, 2023, all United States health care personnel should be screened for TB upon hire. This process includes a risk assessment, symptom evaluation, and TB blood test or TB skin test. If the tuberculin skin test is used to test health care personnel upon hire, the two-step testing should be used. […]

• No harm, potential for more than minimal, isolatedF689Jun 27, 2025

  Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to implement safety interventions for one of three sampled residents at risk for falls. (Resident 5) Findings include: Clinical record review revealed that Resident 5 had diagnoses that included neurocognitive disorder with Lewy body dementia (a progressive brain disorder that can cause cognitive decline, motor problems, sleep disturbances, and visual hallucinations) and seizures. The Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively impaired and dependent on staff for care. […]

• No harm, potential for more than minimal, isolatedF684Oct 24, 2024

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 29 sampled residents. (Resident 99) Findings include: Review of the policy entitled, Administering Medication, last reviewed January 25, 2024, revealed staff were to obtain vital signs if necessary and document physician indicated medication administration information. Clinical record review revealed that Resident 99 had diagnoses that included hypertension (high blood pressure) and cardiomyopathy (the heart muscle is no longer able to pump blood efficiently). On June 8, 2024, the physician ordered staff to administer a blood pressure medicine (losartan potassium) once a day. […]

• No harm, potential for more than minimal, isolatedF641Nov 15, 2023

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's status for one of 36 sampled residents. (Resident 157) Findings include: Clinical record review revealed that Resident 157's MDS assessment dated [DATE], Section C (Brief Interview for Mental Status) was incomplete and Section H (Appliances) inaccurately indicated that the resident had an indwelling catheter. There was no documented evidence or physician's order to reflect that the resident had an indwelling catheter. […]