Faith Lutheran Home: Unsafe Discharge Violation - MT
Staff at the nursing home determined the family members were too drunk to complete admission documents and turned the resident away without contacting administrators or creating any safety plan for her departure.
The incident occurred on June 3, according to a facility incident report reviewed by state inspectors. The resident had arranged to be admitted to Faith Lutheran Home and arrived via contracted ambulance service after the lengthy journey. Her local family met her at the facility, but staff refused to proceed with the admission process.
Nobody called management.
The resident left with her intoxicated family members, and facility staff made no effort to ensure she had a safe place to go or appropriate care arrangements. No discharge plan existed because the facility had never formally admitted her, despite accepting responsibility for her transfer from out of town.
Staff member A told inspectors during a November interview that they learned about the refused admission the next day. Only then did the facility contact the State Survey Agency for guidance on how to handle the situation.
The facility immediately reached out to the resident to check on her safety and discuss potential admission. But the resident had been living with family before her hospitalization and never wanted long-term care placement in the first place. She decided to remain with her family rather than enter the nursing home.
The resident had no immediate medical needs requiring facility-level care, such as IV antibiotics or rehabilitation orders, according to the inspection report.
Faith Lutheran Home suspended the employee who refused the admission. That worker later resigned.
The facility held an emergency quality assurance meeting on June 4 to address the incident and completed staff education about proper admission procedures. The nursing home developed a plan of correction to prevent similar situations.
State inspectors determined the violation represented minimal harm with potential for actual harm to residents. The deficient practice affected few residents and was corrected by June 4, making it past non-compliance by the time of the November inspection.
No other residents have been refused admission since the June incident, according to facility staff.
The case highlights the vulnerability of residents during transfers between care facilities, particularly those traveling long distances for placement. The resident in this case had coordinated her admission and ambulance transport, only to find herself stranded with impaired family members and no backup plan.
Federal regulations require nursing homes to ensure safe transfers and discharges that meet residents' needs and preferences. Facilities must have appropriate discharge planning in place, even when admission plans fall through unexpectedly.
The refused admission created a dangerous situation where a resident who had traveled hours for care was left without proper oversight or safety planning. The family members' intoxication made them unable to participate in necessary paperwork, but staff failed to contact supervisors who might have found alternative solutions.
Faith Lutheran Home's response included immediate outreach to verify the resident's safety and well-being after learning of the incident. The facility's quality assurance team moved quickly to implement corrective measures and staff training.
The resident ultimately remained in her preferred living situation with family, suggesting the nursing home placement may not have been her first choice. However, the lack of communication and safety planning during the refused admission created unnecessary risk and uncertainty for everyone involved.
The employee's resignation following suspension indicates the facility took disciplinary action seriously, though the inspection report doesn't detail what specific policies or training the worker violated.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Faith Lutheran Home from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
FAITH LUTHERAN HOME in WOLF POINT, MT was cited for violations during a health inspection on November 19, 2025.
The incident occurred on June 3, according to a facility incident report reviewed by state inspectors.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.