Lutheran Sunset Home

In the surveyor’s words

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

• Actual harm, isolatedF689May 21, 2024

  1. Based on record review, resident and staff interviews, and review of a facility reported incident, the facility failed to prevent accidents for 1 of 1 sampled resident (Resident #1) reviewed for an accident with subsequent injury. Failure to follow facility policy for proper use of a stand-lift resulted in injury. Findings include: Review of Resident #1's medical record identified diagnoses of osteoarthritis and abnormalities of gait (walking). The care plan identified, . Self-care deficit with mobility related to decreased mobility, . and other risk factors. Assist of 1 with stand aid lift for all transfers. Record review occurred on 05/21/24. The nurse's notes identified the following: 4/30/24 4:08 p.m. CNA [certified nurse aide] called nurse into resident's room @ [at] 6:30 AM. […]

• No harm, potential for more than minimal, patternF584Feb 26, 2026

  Based on observation, review of the facility's policy, review of facility housekeeping checklist, and resident and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 5 of 19 sampled residents (Resident #10, #13, #42, #47, and #82) Failure to maintain clean equipment and ensure a safe, clean, and sanitary environment may result in injuries, diminish the homelike living area for residents, and does not promote overall quality of life. Findings include: Review of the facility policy, Personal Fans, occurred on 02/26/26. This policy, dated February 2025, stated, . Personal fans must be cleaned and disinfected on a routine basis . […]

• No harm, potential for more than minimal, patternF812Feb 26, 2026

  Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure dishware and eating utensils are properly cleaned and sanitized in 1 of 1 kitchenette (Special Care Unit) utilizing a mechanical dish-washing machine. Failure to ensure the mechanical dishwashing machine reaches the proper temperatures for the wash and final rinse cycles may result in unclean and unsanitized dishware and eating utensils. Findings include:The 2022 FDA (Food and Drug Administration) Food Code, Public Health Reasons, pages 172 - 153, stated . 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. The wash solution temperature in mechanical warewashing equipment is critical to proper operation. […]

• No harm, potential for more than minimal, patternF880Dec 19, 2024

  Based on observation, record review, policy review, and staff interview, the facility failed to follow standards of infection control and prevention for 4 of 18 sampled residents (Resident #2, #33, #75, and #236) and 2 supplemental residents (#9 and #43) observed. Failure to practice infection control standards related to enhanced barrier precautions (EBP), transmission-based precautions (TBP), and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Droplet Precautions occurred on 12/19/24. This policy, dated July 2022, stated, Residents suspected of or confirmed to have COVID-19 will be placed on Enhanced Droplet Precautions . Doffing [removing] PPE [personal protective equipment] . […]

• No harm, potential for more than minimal, patternF812Nov 2, 2023

  Based on observation, facility documentation, and staff interview, the facility failed to serve, prepare, and store food in a safe and sanitary manner for 1 of 1 kitchen. Failure to discard spoiled food and protect dishware from contamination has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: Observation of the main kitchen and walk-in cooler occurred on 10/30/23 at 12:40 p.m. and showed the following: * Two unopened containers of strawberries, with visible mold present. * One unopened container of cherry tomatoes, shriveled and covered with dark spots. * One open, undated bag of shredded lettuce, with visible browning present. * A tabletop fan visibly soiled with dust blowing in the direction of clean dishes. […]