Lutheran Home, The

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Feb 9, 2024

  Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 168. Review of the facility's policy titled, Cleaning and Sanitation of Dining and Food Service Areas, dated 11/14/23, showed: - The dining service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule; - The Certified Dietary Manager (CDM)/dining service director/kitchen manager/designee will record all cleaning and sanitation tasks for the department; - All staff will be trained on the frequency of… […]

• No harm, potential for more than minimal, patternF568Jul 10, 2026

  Based on interview and record review, the facility failed to maintain a system to safeguard resident trust petty cash by commingling money from other sources with resident trust petty cash and by failing to reconcile the resident trust petty cash account. This had the potential to affect all residents whose funds were maintained by the facility. The facility census was 181.The facility did not provide a policy regarding the management, reconciliation, and safeguarding of resident trust petty cash. Observation of the resident petty cash box count and review of the petty cash log on 07/10/26 at 11:15 A.M., showed:- Administrative Assistant E counted $474.50 in resident trust petty cash. The petty cash log showed receipts totaling $435.38. […]

• No harm, potential for more than minimal, isolatedF641Jul 10, 2026

  Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) assessments accurately reflected residents' clinical status for two (Residents #12 and #18) out of 35 sampled residents. The facility inaccurately coded Resident #12 as receiving hospice services when the resident was not enrolled in hospice and inaccurately coded Resident #18 as receiving insulin during the MDS look-back period when no insulin was administered. These inaccurate assessments had the potential to affect resident care planning, quality measures, and the accuracy of federally required resident assessment data. […]

• No harm, potential for more than minimal, isolatedF658Jul 10, 2026

  Based on interview and record review, the facility failed to follow physician orders by failing to administer a physician-ordered as needed (PRN) antihypertensive medication when the systolic blood pressure (SBP - top number. Normal range: 90-120) exceeded the ordered treatment parameter of greater than 160 millimeters of mercury (mmHg) for one resident (Resident #173) out of 35 sampled residents. The facility census was 181.Review of the facility policy titled, Medication Transcription, undated, showed:- PRN ordered medications are administered only as needed according to a designated time frame identified in the order;- The licensed nurse assesses the resident and makes the decision when to administer the PRN medication. 1. […]

• No harm, potential for more than minimal, isolatedF699Jul 10, 2026

  Based on interview and record review, the facility failed to develop and implement an individualized, person-centered care plan to address post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event) triggers and interventions for one (Resident #7) of three sampled residents reviewed for behavioral health. Although the resident had a diagnosis of PTSD, documented trauma history, and identified individualized triggers and care preferences, the facility failed to identify those triggers or interventions on the resident's care plan. […]