Faith Lutheran Home

Inspectors wroteBased on interview and record review, the facility failed to submit reportable incidents to the State Survey Agency, within 24 hours of the incident, for 7 (#s 13, 14, 15, 22, 25, 29, and 38) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide 12 hours of in-service training per year, including dementia management, for Certified Nursing Assistants. This deficient practice had the potential to affect all residents with dementia or altered cognition in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, and/or the resident's representative, were made aware of the risks and benefits associated with the use of psychotropic medications prior to the start of treatment for 2 (#s 2 and 3) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an as needed psychotropic medication was limited to 14 days, unless the rationale for continuing the medication was documented by a medical provider, for 1 (#2) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Quarterly Minimum Data Set (MDS) assessment for a resident receiving hypoglycemic medication for 1 (#7); and failed to accurately complete a Comprehensive MDS assessment for 1 (#5) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist identified and reported an as needed psychotropic medication being used in excessive duration for 1 (#2) of 17 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of the COVID-19 vaccination status (received or refused) for staff member E.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was discharged in a safe condition after previously accepting admission and responsibility for the resident from out of town for 1 (#1) of 1 resident sampled for inappropriate discharge. This deficient practice was corrected on 6/4/25 and determined to be past non-compliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure MDS assessments were completed, encoded, and transmitted, within the required timeframe, for 1 (#196) of 14 sampled residents, and failed to ensure the assigned staff member had the knowledge necessary to correct MDS transmission errors. The failures resulted in inaccurate and missing MDS data, which was identified during the annual recertification survey process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status, or meal safety for those who consumed food prepared and served by the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen and the dietary storage areas; failed to ensure kitchen staff labeled and dated food in the coolers; and failed to maintain a clean kitchen environment. The deficient practices increased the risk for the development of foodborne illnesses and unsanitary conditions, for all residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enhanced barrier precautions were followed for 1 (#22) of 14 sampled residents; and failed to to maintain an adequate infection surveillance and antibiotic stewardship program and ensure policies and procedures were reviewed and revised annually for the Infection Prevention and Control Program. The deficient practices had the potential to increase the risk of infections within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation for screening of medical contraindications, education, and signed consent or declination by the resident or their responsible party for the influenza vaccination for 4 (#s 3, 7, 13, and 31) of 5 sampled residents. This increased the risk of residents not being informed of risks and benefits to the vaccination and verification of resident or responsible party authorization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement, and operationalize a facility policy and procedure for grievances, and insure grievance information was readily accessible, to include the name and contact information for the grievance official; failed to provide residents with readily available grievance forms, as noticed by at least 1, resident (#196), of 14 sampled; and failed to provide residents with the option to file grievances anonymously.

Inspectors wroteBased on interview and record review, the facility failed to revise a resident care plan to address comfort care for 1 (#31) of 14 sampled residents. This failure placed the resident at risk for not receiving appropriate comfort care measures.

Inspectors wroteBased on interview and record review, the facilty failed to ensure residents who received dialysis were provided services, consistent with professional standards of practice, to include physician orders for the dialysis, for 1 (#22) of 14 sampled residents. The deficient practices placed the resident at risk for pre-dialysis and post-dialysis complications.

Inspectors wroteBased on interview and record review, the facility failed to adhere to the participation requirements for long-term care facilities, related to the lack of appointing a licensed Nursing Home Administrator, who has an active license for Montana. This failure did not allow the facility to maintain compliance for the Requirements of Participation, and may negatively affect all residents at the facility.

Inspectors wroteBased on interview and record review, the facility's governing body failed to employ an administrator that was licensed in the State of Montana. This failure has affected all residents at the facility, due to the lack of an Administrator, and the facility not being in substantial compliance due to this.

Inspectors wroteBased on interview and record review, the facility failed to follow and uphold the plan of correction for the survey dated 12/3/2024, as the QAPI committee did not meet monthly to identify ongoing issues and concerns related to the survey or faiclity, and ensure a licensed Administrator was present, which may negatively affect any resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure privacy during wound measurement and ointment application, for 1 (#25) of 9 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with individualized care needs, related to falls and prevention of falls, had identified fall interventions implemented and in place, so care was provided care in a manner to promote the well-being and prevent further falls, for 1 (#51) of 9 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with individualized care needs, related to falls and prevention of falls, had identified fall interventions implemented and in place, so care was provided care in a manner to promote the well-being and prevent further falls, for 1 (#51) of 9 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to identify a resident's elopement risk or implement interventions following an elopement for 1 (#31) of 4 residents sampled for elopement, and failed to implement, monitor, and modify fall interventions to prevent multiple falls for 1 (#50) of 6 residents sampled for falls.

Inspectors wroteBased on observation and interview, the facility failed to provide sufficient privacy between residents with a shared bathroom due to the use of a curtain for 1 (#17) and failed to provide privacy during cares for 1 (#23) of 2 residents sampled for privacy concerns, and failed to ensure the privacy curtains could be closed adequately to provide visual privacy for residents in four rooms, 304, 305, 306, and 308.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and consistently document restorative nursing services intended to improve or maintain mobility for 3 (#s 13, 31, and 46) of 9 residents sampled for restorative services.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide food at a palatable temperature for 3 (#s 4, 20, and 46) of 21 sampled residents. The failure had the ability to affect all residents who eat food from the kitchen in the facility.

Inspectors wroteBased on interview and record review, the facility failed to update a resident care plan in a timely manner for elopement for 1 (#31) of 5 residents sampled for elopement, and failed to revise a resident care plan to show effective fall risk interventions following repeated falls with injury for 1 (#50) of 6 residents sampled for falls.

Inspectors wroteBased on observations, interview, and record review, the facility failed to monitor and control the temperature of the personal resident room refrigerators, and ensure food safety with the use of them, per the facility policy, for 2 (#12 and #17) of 3 sampled residents with refrigerators.