Strawberry Point Lutheran Home

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF580Jun 17, 2026

  Based on record review, guardian interview, and staff interview the facility failed to ensure a resident's legally appointed guardian received timely notification regarding medication changes and equipment management issues regarding hearing aids for 1 of 3 residents reviewed (Resident #17). The facility reported a census of 15 residents. Findings include: The Minimum Data Set, dated [DATE] documented that Resident #17 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. The assessment noted Resident #17 had moderate difficulty with hearing, and used a hearing aid or other hearing appliance. […]

• No harm, potential for more than minimal, isolatedF640Jun 17, 2026

  Based on the review of electronic health records (EHR), the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025, and staff interviews, the facility failed to complete and submit Minimum Data Set (MDS) assessments as required for 2 of 2 sampled residents (Resident #15 and Resident #3). The facility reported a census of 15 residents.Findings Include:1. Review of the facility Census List on 6/16/26 for Resident #15 revealed he was admitted to the facility on [DATE] and passed away on 3/17/26. Resident #15's Minimum Data Set (MDS) log in the Electronic Health Record (EHR) reviewed on 6/16/26 lacked a Death in Facility Tracking MDS. The review revealed the facility staff had not started or completed this tracking record. […]

• No harm, potential for more than minimal, isolatedF641Jun 17, 2026

  Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment to reflect Preadmission Screening and Resident Review (PASRR) status for 1 of 3 residents reviewed (Resident #16). The facility reported a census of 15 residents. Findings include: The MDS dated [DATE] for Resident #16 documented the resident was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Resident #16's current PASRR document dated October 2023 documented a notice of a PASRR Level II Outcome. […]

• No harm, potential for more than minimal, isolatedF689Apr 24, 2025

  Based on observation, record review, staff interviews, and policy review the facility failed to ensure 1 of 3 residents at risk for elopement from the facility remained in the facility (Resident #9). The facility reported a census of 15 residents. Findings include: The Minimum Data Set (MDS) for Resident #9 dated 2/10/25 documented a Brief Interview of Mental Status (BIMS) of 9 indicating moderate cognitive impairment. The MDS revealed she is independent without staff assistance for dressing, bed mobility, transferring, and walking. The MDS also documented diagnoses of Wernicke's encephalopathy, cognitive communication deficit, and hypertension. […]

• No harm, potential for more than minimal, isolatedF684Feb 3, 2025

  Based on staff interviews,review of clinical records, and facility policy review, the facility failed to provide assessment and intervention in a timely manner when one of three residents reviewed had a change in condition. (Resident #1). The facility reported a census of 13 residents. Findings include: The MDS (Minimum Data Set), an assessment tool dated 12/24/2024 revealed Resident #1 had diagnoses including renal insufficiency, post traumatic stress disorder, cancer, medically complex condition, anemia, and heart failure. The resident had no cognitive impairment and required partial assistance to transfer and used a wheel chair for locomotion. […]