The Vinton Lutheran Home

In the surveyor’s words

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

• Immediate jeopardy, patternF689Oct 21, 2025

  Based on observations, clinical record review, facility investigation, manufacturers user manuals, staff interviews and policy review, the facility failed to operate a full body mechanical lift appropriately during resident cares, and failed to use the appropriate slings for the mechanical lift for 3 of 5 residents (Resident #1, #2, #3) reviewed for safe transfers. This failure resulted in an immediate jeopardy when Lift #1's (brand specific) spreader bar had over a 1 centimeter (CM) gap between the hook cradle and the rubber stopper. When staff failed to clear Resident #1 bottom over a bed wedge cushion, the lift sling strap lifted up off the spreader bar hook, resulting in Resident #1 falling to the floor with a 3 - 4 CM (centimeter) gash to the back of her head. […]

• Actual harm, isolatedF689Dec 4, 2024

  Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to provide appropriate supervision while transporting a resident in the wheelchair that resulted in injury for one of three residents' reviewed. (Resident #1). The facility reported a census of 44 residents. Findings include: The MDS (Minimum Data Set) dated 10/10/2024 revealed Resident #1 had severe cognitive impairment, required substantial/maximum assistance of staff for transfers from one surface to another, and used a wheelchair for locomotion. The resident had diagnoses including Alzheimer's disease, osteoarthritis and hypertension. […]

• No harm, potential for more than minimal, widespreadF801Jan 20, 2023

  Based on review of personnel files and staff interviews, the facility failed to ensure that the Director of Food and/or Nutrition Services met minimum qualifications. This has the potential to affect the total census of 35 residents. Findings include: Interview with the Dining Services Director on 1/17/23 at 9:45 AM revealed the Dietician visits one time weekly for eight hours. He went on to state that he did not have a Certificate for Dietary Manager. He is enrolled in a Dietary Manager Certificate program as of May of 2022 but has not completed the first segment of the program. Review of the Dining Services Director personnel file revealed a hire date of April 21, 2021 as a cook and then later got promoted to the Dining Services Director in April of 2022. […]

• No harm, potential for more than minimal, widespreadF803Jan 20, 2023

  Based on review of the facility menus, resident observations, observations of meal service, resident, and staff interviews the facility failed to ensure that one of four residents reviewed (Resident (R)33) on a pureed diet had food choices. In addition, the facility failed to have one of seven lunch menus reviewed for nutritional adequacy. Findings include: Review of the Electronic Medical Record (EMR) for R33 included diagnoses of dysphagia and weakness. In addition, the resident was receiving palliative care services. The Weights/Vitals tab revealed that from August 2022 to January 2023, R33 has lost 15.36% of her body weight, 114.6 pounds to 97.0 pounds. […]

• No harm, potential for more than minimal, widespreadF812Jan 20, 2023

  Based on observations, staff interviews, review of policy and procedures, the facility failed to ensure that it stored and served food in accordance with the product food label. The problem can affect all 35 residents. Findings include: 1. On 1/17/23 at 11:15 AM observed the resident's food refrigerator located in the medication room on the 2-North unit revealed two Mighty Shakes in the refrigerator section. Each shake lacked a thaw date. The product label reads, store frozen, thaw at or below 40 degrees. Use the thawed product within 14 days. Keep Refrigerated. Interview with the Dining Service Director at the time of the observation indicated the dining room staff stock the 2-north refrigerator and are responsible for the storage of these two Mighty Shakes. […]